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Anatomical anterior cruciate ligament reconstruction (ACLR) results in fewer rates of atraumatic graft rupture, and higher rates of rotatory knee stability: a meta-analysis
  1. Yousif Eliya1,
  2. Khaled Nawar2,
  3. Benjamin B Rothrauff3,
  4. Bryson P Lesniak3,
  5. Volker Musahl3,
  6. Darren de SA4
  1. 1 Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
  2. 2 MacSports Research Program, McMaster University, Hamilton, ON, Canada
  3. 3 Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  4. 4 Department of Surgery, Division of Pediatric Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Darren de SA, Department of Surgery, Division of Pediatric Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; darren.desa{at}


Importance This review highlights the differences in outcomes between anatomical and non-anatomical anterior cruciate ligament reconstruction (ACLR) techniques.

Objective To compare clinical and functional outcomes between anatomical and non-anatomical ACLR techniques.

Evidence review A search of MEDLINE, Embase and PubMed from 1 January 2000 to 24 October 2019 was conducted. Randomised and prospective primary ACLR studies using autograft and a minimum of 2 years of follow-up were included. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist (AARSC) was used to categorise studies as anatomical. Outcomes analysed included failure rate, knee stability and functional outcomes. A meta-analysis using risk ratio and mean differences was conducted using a random effects model.

Findings Thirty-six studies were included, representing 3710 patients with a follow-up range of 24–300 months. The overall failure rate was 96/1470 (6.5%) and 131/1952 (6.7%) in the anatomical group and non-anatomical group, respectively. The pooled results of the overall failure rate showed that there was no statistically significant difference between the anatomical and the non-anatomical groups (p=0.96). There were 37/60 (61.7%) and 29/67 (43.3%) traumatic failures in the anatomical and non-anatomical groups, respectively. The number of patients with the negative postoperative pivot-shift test was 995/1252 (79.5%) and 1140/1589 (71.1%) in the anatomical and non-anatomical groups, respectively. The pooled results indicated a statistically significant higher number of patients with a positive pivot shift in the non-anatomical group compared with the anatomical group (p=0.03).

Conclusions and relevance This study demonstrated that the overall failure rate was similar between the anatomical and non-anatomical approaches. However, the anatomical ACLR demonstrated a significantly superior restoration of rotatory stability, as evidenced by a higher percentage with a negative postoperative pivot-shift test. Non-anatomical ACLR resulted in higher rates of atraumatic graft ruptures and persistent rotatory knee instability. Surgeons should consider anatomical ACLR when treating rotatory knee stability in patients.

Level of evidence II, systematic review and meta-analysis of level I and II studies.

  • anterior cruciate ligament
  • arthroscopy
  • anatomical location
  • autografts
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  • YE and KN contributed equally.

  • Contributors YE and KN conducted the literature search and determined studies for inclusion and exclusion. YE and KN extracted data from the studies included, performed the meta-analysis and drafted the manuscript. BBR, DdS, KN and YE conceived the idea of the study, designed the study and critically revised the manuscript for important intellectual content. DdS, BBR, BPL and VM contributed to data analysis, drafting and revising the article. All authors gave final the approval of the version to be published and agreed to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests VM reports grants from Smith & Nephew, grants from Arthrex, other from University of Michigan, other from Steadman Clinic and Steadman Philippon Research Institute, outside the submitted work; in addition, VM has a patent 'quantified injury diagnostics' issued.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. All data were obtained from published literature as this is a systematic review.

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