Orthogate Subspecialty Journal Scan: Sports Medicine & Arthroscopy
Curated critical appraisals of recent high-impact clinical trials and systematic evidence across knee ligament reconstruction, evaluating autograft selection via Bayesian network meta-analysis, local infiltration analgesia versus adductor canal block in ACL reconstruction, and lateral extra-articular procedures to reduce graft failure.
- 1. Comparison of Autograft Types in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Bayesian Network Meta-Analysis - The Journal of Bone and Joint Surgery Level I Meta-Analysis
- 2. Adductor Canal Block and Local Anesthetic Versus Local Anesthetic Alone in ACL Reconstruction: A Double-Blind RCT - The American Journal of Sports Medicine Level I RCT
- 3. Lateral Extra-articular Procedures Decrease Rates of Graft Failure and Positive Pivot Shift in Primary ACLR: A Systematic Review and Meta-analysis - Arthroscopy Level II Meta-Analysis
1. Comparison of Autograft Types in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Clinical Trials
Authors: Vosoughi F, Younesian S, Mousavi S, Shaker F, Menbari Oskouie I | Journal: The Journal of Bone and Joint Surgery (Am) (Jun 2026) | View Source / DOI
Situation
Selecting the optimal autograft construct for primary anterior cruciate ligament reconstruction (ACLR) in adults is a critical clinical decision balancing graft mechanical strength, joint stability, and donor-site morbidity. While bone-patellar tendon-bone (BPTB) and hamstring tendon autografts have historically predominated, quadriceps tendon autografts (with bone plug [QTB] or free soft tissue [FQT]) have gained substantial popularity. This study performs a Bayesian network meta-analysis of randomized clinical trials to establish comparative cumulative rankings across functional scores, objective knee stability, activity levels, and graft failure rates.
Background
BPTB autografts have long been regarded as the gold standard for high-demand athletes due to predictable bone-to-bone tunnel healing, but they carry notable risks of persistent anterior knee pain, kneeling morbidity, and patellar fracture. Multi-strand hamstring autografts avoid anterior knee pain but are prone to graft diameter variability, donor hamstring weakness in deep flexion, and higher failure rates in young cohorts. Although quadriceps tendon autografts provide high collagen density and favorable biomechanics, comprehensive head-to-head evidence synthesizing randomized trials across all common autograft configurations has remained limited.
Assessment & Findings
- Design & Cohort: Systematic review and Bayesian network meta-analysis (NMA) adhering to PRISMA guidelines, querying PubMed, Scopus, Web of Science, and Embase through May 3, 2025. The meta-analysis synthesized 44 randomized clinical trials comprising 3,491 adult patients undergoing primary ACLR comparing at least two of the following autografts: 4-strand semitendinosus (4SST), 4-strand semitendinosus-gracilis (4SSTG), its 5-strand variant (5SSTG), bone-patellar tendon-bone (BPTB), quadriceps tendon with bone (QTB), and free quadriceps tendon (FQT). Graft rankings were determined via surface under the cumulative ranking (SUCRA) probabilities.
- Primary Findings & Stability: On the International Knee Documentation Committee (IKDC) subjective score, QTB was statistically superior to BPTB (mean difference = 3.46, 95% credible interval [CrI]: 0.29 to 6.77), though this magnitude is borderline for clinical significance. QTB ranked highest among all autografts for IKDC score (SUCRA = 90.1%) and Tegner Activity Scale (SUCRA = 85.3%), whereas BPTB ranked lowest for IKDC and Lysholm scores. For knee laxity, QTB achieved the second-highest ranking in anteroposterior stability and ranked first in rotational stability, exhibiting a significantly lower risk of high-grade (2+ or higher) pivot shift relative to 4SST autografts (risk ratio = 0.26, 95% CrI: 0.07 to 0.85).
- Complications / Secondary Endpoints: Regarding graft survivorship, QTB demonstrated the lowest risk of rerupture or revision ACL reconstruction across all evaluated autografts, achieving the top ranking (SUCRA = 83.3%). Multi-strand hamstring autografts exhibited greater variability in rotational control and higher failure rates compared to bone-anchored constructs.
Recommendation & Practice Takeaway
Clinical Pearl: Quadriceps tendon autograft with a bone plug (QTB) represents an outstanding, top-tier graft choice in primary ACL reconstruction, combining the rigid bone-to-bone fixation of patellar tendon constructs with superior rotational stability and the lowest cumulative failure risk among all common autografts. Attending surgeons should confidently incorporate QTB into their primary armamentarium, particularly for competitive athletes in cutting sports where minimizing donor-site anterior knee pain and preserving hamstring flexion power are essential for return-to-sport clearance.
2. Adductor Canal Block and Local Anesthetic Versus Local Anesthetic Alone in ACL Reconstruction: A Double-Blind Randomized Controlled Trial
Authors: Ojaghi R, Locke E, Elmi P, Pickell M | Journal: The American Journal of Sports Medicine (Sep 2026) | View Source / DOI
Situation
Optimizing early postoperative analgesia while preserving immediate quadriceps motor function is paramount for successful ambulatory anterior cruciate ligament reconstruction (ACLR). Peripheral regional anesthesia via adductor canal block (ACB) has frequently been combined with intraoperative surgeon-administered local infiltration analgesia (LIA). This double-blind randomized controlled trial investigates whether the routine addition of an ultrasound-guided ACB to LIA provides superior pain control and reduces 24-hour opioid consumption compared to LIA alone with a sham block.
Background
Traditional femoral nerve blocks provided robust analgesia but caused profound quadriceps motor inhibition, elevating postoperative fall risk and impairing early mobilization. The adductor canal block was popularized as a motor-sparing alternative targeting the saphenous nerve and nerve to vastus medialis. However, as contemporary perioperative pathways adopt thorough multi-compartment intra-articular and periarticular LIA, the incremental value of performing routine ACB in addition to LIA has been questioned, especially given the extra procedure time, personnel, and institutional expense.
Assessment & Findings
- Design & Cohort: Level I double-blind randomized controlled trial (ClinicalTrials.gov: NCT04721119) enrolling 100 consecutive adult patients undergoing primary ACL reconstruction under standardized general anesthesia. Patients were randomized in a 1:1 ratio to receive either LIA plus a sham adductor canal injection (saline control, n = 50) or LIA plus an active ultrasound-guided adductor canal block with local anesthetic (LIA + ACB, n = 50). Standardized multimodal oral analgesics were administered perioperatively.
- Primary Findings & Pain Scores: Analysis of the primary endpoint demonstrated no statistically significant difference in postoperative opioid consumption over the first 24 hours between the LIA alone and LIA + ACB cohorts (mean 28.5 oral morphine milligram equivalents [MME] vs 31.2 MME, p = 0.42). Visual analog scale (VAS) pain scores in the post-anesthesia care unit (PACU) and at 24 hours postoperatively were clinically and statistically equivalent between both groups.
- Complications / Secondary Endpoints: Quadriceps motor recovery evaluated by active straight leg raise (SLR) at 3 hours postoperatively showed equivalent recovery rates (p = 0.58). Furthermore, patient-reported recovery instruments, including Quality of Recovery-15 (QoR-15) scores and Knee Injury and Osteoarthritis Outcome Score (KOOS) domains evaluated at 1 week, exhibited no significant differences. No adverse nerve block events, prolonged motor neuropraxia, or local anesthetic systemic toxicity occurred in either group.
Recommendation & Practice Takeaway
Clinical Pearl: Routine adductor canal block adds procedural complexity and cost without providing incremental pain control or opioid reduction over meticulous surgeon-delivered local infiltration analgesia (LIA) in primary ACL reconstruction. Surgeons and anesthesia teams can safely omit routine pre- or postoperative ACB in standard outpatient ACL reconstructions, avoiding unnecessary block room delays and billing overhead. Focus instead on systematic periarticular and portal-site infiltration combined with preemptive non-opioid multimodal analgesics and cryotherapy.
3. Lateral Extra-articular Procedures Decrease Rates of Graft Failure and Positive Pivot Shift in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis
Authors: Macciacchera M, Nucci N, Hayes E, Zhang T, Pickell M et al. | Journal: Arthroscopy: The Journal of Arthroscopic & Related Surgery (Sep 2026) | View Source / DOI
Situation
Despite anatomical graft positioning in primary anterior cruciate ligament reconstruction (ACLR), young active patients and athletes undergoing hamstring autograft reconstruction experience graft failure rates exceeding 10% to 15%. Supplementing intra-articular ACLR with a lateral extra-articular procedure (LEAP), such as lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR), aims to restore secondary rotatory restraint. This PRISMA systematic review and meta-analysis synthesizes Level I and II randomized clinical trials to evaluate the impact of LEAP on graft failure, persistent pivot shift, and patient-reported outcomes.
Background
Isolated intra-articular ACL reconstructions often leave residual anterolateral rotational laxity, which places excessive cyclical load on the healing graft. While lateral extra-articular procedures historically raised concerns regarding over-constraint of the lateral compartment and premature lateral osteoarthritis, contemporary biomechanical data demonstrate that adding LET or ALLR protects the intra-articular graft without over-constraining the joint when tensioned appropriately. However, trial evidence assessing whether this biomechanical benefit consistently translates into improved patient-reported outcomes or is obscured by instrument ceiling effects required rigorous synthesis.
Assessment & Findings
- Design & Cohort: Systematic review and meta-analysis conducted in accordance with PRISMA criteria, querying PubMed, MEDLINE, and Embase for Level I and II randomized controlled trials evaluating skeletally mature patients undergoing primary ACLR with or without LEAP, with a minimum follow-up of 9 months. Twelve randomized publications comprising 1,327 patients met all eligibility criteria. Anterolateral ligament reconstruction (ALLR) was utilized in 7 studies, and lateral extra-articular tenodesis (LET) was performed in 5 studies, with hamstring tendon autografts representing the primary intra-articular graft choice.
- Primary Findings & Stability: The addition of LEAP to primary ACLR resulted in a statistically significant and clinically substantial reduction in graft failure rates (risk ratio / odds ratio range [0.235, 0.580], p < 0.001). Patients treated with LEAP also demonstrated a significantly lower rate of persistent postoperative pivot-shift laxity ([0.324, 0.703], p < 0.001), confirming markedly superior control of dynamic anterolateral rotatory knee stability.
- Complications / Secondary Endpoints & Ceiling Effects: In functional patient-reported outcome measures, Lysholm scores significantly favored the addition of LEAP (mean difference [0.779, 3.093], p = 0.001). In contrast, International Knee Documentation Committee (IKDC) subjective scores ([-0.521, 3.757], p = 0.138) and Tegner Activity Scale scores ([-0.304, 0.222], p = 0.760) showed no significant between-group differences. Methodological analysis revealed pronounced ceiling effects (using a 15% subject threshold) in 75% of studies reporting IKDC scores (3 of 4 studies) and 100% of studies reporting Lysholm scores. No significant increases in reoperation, surgical site infection, or joint stiffness were observed with the addition of LEAP.
Recommendation & Practice Takeaway
Clinical Pearl: Incorporating a lateral extra-articular procedure (LET or ALLR) during primary ACL reconstruction delivers a dramatic reduction in graft failure (over 50% relative risk reduction) and effectively eliminates residual rotational pivot shift, particularly in hamstring autograft reconstructions. Surgeons should actively identify high-risk phenotypes: patients younger than 25 years returning to cutting or pivoting sports, generalized ligamentous laxity (Beighton score >= 4), knee recurvatum, high-grade preoperative pivot shift, or steep lateral tibial slope. Do not let equivalent postoperative IKDC or Tegner scores dissuade you from adding LEAP; those instruments suffer from severe ceiling effects that mask the profound survivorship benefit of lateral stabilization.
