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Appendix 2. Characteristics of Studies Included in the Meta-Analysis
The eight clinical trials [1-8] included in the study were published between 1994 and
2014 and involved a total of 682 participants who were primarily young, active patients.
Most were men (men to women ratio 2.17:1), and mean patient age ranged from 21.9 to
29.5 years. The mean interval from injury to ACL reconstruction ranged from 1 to 36.6 months and mean followup ranged from 12 to 84 months. The three most reported outcome measures were the IKDC objective knee evaluation score, pivot-shift test results, and overall complications, which were reported in eight trials (Table 1).
Four studies [1, 2, 4, 6] compared intraarticular ACL reconstruction using bone-patellar tendon-bone (BPTB) graft with intraarticular ACL reconstruction with BPTB graft combined with an extraarticular reconstruction. One study [5] compared results after intraarticular ACL reconstruction with hamstring tendon graft, with or without extraarticular tenodesis. Another trial [7] compared intraarticular double-bundle reconstruction with combined intraarticular and extraarticular double-bundle reconstruction. Two studies [3, 8] compared three techniques: (1) intraarticular reconstruction using a BPTB graft; (2) intraarticular reconstruction using a hamstring tendon graft; and (3) intraarticular reconstruction using a hamstring tendon graft combined with an extraarticular procedure (Table 2).
Although a total of six different extraarticular techniques were evaluated in the trials included in our review, pooling them into a single category of combined intra- and extraarticular ACL reconstruction was appropriate because homogeneity of most outcome measures was evident. Heterogeneity was null for most outcomes (IKDC objective knee evaluation, pivot shift test, return to previous activity level, radiographic degenerative changes, and overall complications). Thus, subgroup analyses for different

A2-2 types of extraarticular reconstruction were not conducted. Regarding the few heterogeneous outcomes that were observed (IKDC subjective knee evaluation, Tegner
Lysholm score, and KT-1000 side-to-side difference), few studies were available for meta-analysis; therefore, they were randomly pooled to decrease the effects of discrepancies in the data.
References
1.
Acquitter Y , Hulet C , Locker B , Delbarre JC , Jambou S , Vielpeau C . [Patellar tendon-bone autograft reconstruction of the anterior cruciate ligament for advanced-stage chronic anterior laxity: is an extra-articular plasty necessary? A prospective randomized study of 100 patients with five-year follow-up] [In French].
Rev Chir Orthop Reparatrice Appar Mot.
2003;89:413-422.
2.
Ait Si Selmi T, Fabie F, Massouh T, Adeleine P, Neyret P. Greffe du LC. au tendon rotulien sous arthroscopie avec ou sans plastie antero externe: etude prospective randomisée a propos de 120 cas.
Les Journées Lyonnaises de Chirurgie du Genou. 2002.
3.
Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior cruciate ligament reconstruction: a prospective randomized study of three surgical methods. Am J Sports Med . 2001; 29:272-279.
4.
Giraud B , Besse JL ,
Cladière F
, Ecochard R , Moyen B , Lerat JL . [Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by quadricipital tendon plasty: seven-year follow-up] [In French]. Rev Chir Orthop Reparatrice Appar
Mot .
2006;92:788-797.
5. Goertzen M, Schulitz KP. [Isolated intraarticular plasty of the semitendinosus or combined intra- and extra-articular plasty in chronic anterior laxity of the knee] [In French]. Rev Chir Orthop
Reparatrice Appar Mot. 1994;80:113-117.

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6. Trichine F, Alsaati M, Chouteau J, Moyen B, Bouzitouna M, Maza R. Patellar tendon autograft reconstruction of the anterior cruciate ligament with and without lateral plasty in advancedstage chronic laxity: a clinical, prospective, randomized, single-blind study using passive dynamic
X-rays. Knee. 2014;21:58-65.
7. Zaffagnini S, Bruni D, Russo A, Takazawa Y, Lo Presti M, Giordano G, Marcacci M. ST/G
ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at
3-year follow-up. Scand J Med Sci Sports.
2008;18:573-581.
8.
Zaffagnini S , Marcacci M , Lo Presti M , Giordano G , Iacono F , Neri MP . Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up. Knee Surg Sports Traumatol Arthrosc.
2006;14:1060-1069.
Table 1.
Patient demographic characteristics and outcomes of included studies
Study & country
Acquitter et al. [1]
France
Total Participants participants evaluated
(number)
100 100
Mean age
(years)
27.1
Mean followup
(months)
58
Men patients
(%)
72
Ait Si Selmi et al. [2]
France
Anderson et al. [3]
USA
Giraud et al.
[4]
France
120
105
63
107
102
63
27.6
21.9
27.6
17.5
35.4
97.5
N/A
64.7
74.7
Postoperative outcomes
IKDC score, radiographic degenerative changes, return to previous activity level, ROM,
KT-1000 score, pivot shift test,
Lachman test, adverse events
IKDC score, pivot shift test,
Lachman test, adverse events
IKDC score, KT-1000 score, pivot shift test, adverse events
IKDC score, KT-1000 score, pivot shift test, Lachman test, adverse events
Goertzen &
Schulitz [5] 56 56 27.5 12 66
Lysholm score, Tegner
Lysholm scale, radiographic

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Germany
Trichine et al.
[6] Algeria 120 107 29.5 24 N/A degenerative changes, KT-1000 score, pivot shift test, Lachman test, adverse events
IKDC score, pivot shift test,
Lachman test, return to previous level of activity, adverse events, pain scale
Zaffagnini et al. [8]
Italy
75 75 28.1 60 65
IKDC score, Tegner Lysholm scale, pain scale, pivot shift test, Lachman test, KT-2000 score, ROM, time to return to previous sports, radiographic degenerative changes
Zaffagnini et al. [7]
Italy
100 72 26.5 46.8 55.5
IKDC score, Tegner Lysholm scale, pain scale, pivot shift test, Lachman test, KT-2000 score, ROM, time to return to previous sports, radiographic degenerative changes
N/A = not available.
Table 2.
Characteristics of interventions of the included studies
Study & country Graft type Type of ACL extraarticular reconstruction
Type of ACL intraarticular reconstruction
Acquitter et al. [1] France
Ait Si Selmi et al. [2]
France
Anderson et al. [3]
USA
BPTB (both groups)
ACL intraaarticular reconstruction
(both groups):
BPTB
ACL extraarticular reconstruction semitendinosus gracilis graft
ACL intraaarticular reconstruction
BPTB, semitendinosus gracilis graft
Mac InJones technique: BPTB with a quadriceps tendon strip
Lemaire technique: semitendinosus gracilis graft
Loose technique: iliotibial band tenodesis
Both groups outside-in (twoincision technique)
Both groups outside-in (twoincision technique)
I Transtibial (oneincision) BPTB
II Outside-in
(two-incision)
Semitendinosus gracilis graft
Femoral graft fixation Tibial graft fixation
Interference screw Interference screw
No fixation
I Interference screw in the femur
II Staples in the femur
III Staples in the femur
Interference screw with post fixation with a screw and washer
I Two staples in the tibia
II Figure-8 stitches in tibia
III Figure-8 stitches in tibia

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Giraud et al.
[4] France
Goertzen &
Schulitz [5]
Germany
Trichine et al.
[6]
Algeria
Zaffagnini et al. [8]
Italy
Zaffagnini et al. [7]
Italy
ACL extraarticular reconstruction semitendinosus gracilis graft
BPTB (both groups)
Semitendinosus graft
BPTB (both groups)
BPTB (Group I)
Semitendinosus gracilis graft
(Groups II and
III)
Semitendinosus gracilis graft
(both groups)
III Outside-in
(two-incision) semitendinosus gracilis graft
Mac InJones technique: BPTB with quadriceps tendon strip
Jäger-Wirth technique: iliotibial band tenodesis
Christel technique: iliotibial band tenodesis
Marcacci technique: semitendinosus gracilis graft, prolongation of
ACL intraarticular reconstruction
(Group III)
Marcacci technique: semitendinosus gracilis graft prolongation of
ACL intraarticular reconstruction
Both groups outside-in (twoincision technique)
Both groups outside-in (twoincision technique)
Both groups transtibial (oneincision technique)
I Transtibial (oneincision) BPTB
II Transtibial
(one-incision) semitendinosus gracilis graft
III Over-the-top semitendinosus gracilis graft + extraarticular augmentation
I Double-bundle
(anteromedial bundle = over-thetop; posterolateral bundle = transportal) semitendinosus gracilis graft
II Over-the-top semitendinosus gracilis graft + extraarticular augmentation
No fixation
Staples
Interference screw Interference screw
I Interference screw
II Endobutton
III Two staples
I Anteromedial bundle = staples,
Posteromedial bundle = no fixation
II Two staples
Interference screw
Semitendinosus graft left attached plus staples
I, II Interference screw
III Semitendinosus gracilis graft left attached + staples
Semitendinosus gracilis graft left attached + staples or suture knots tied over screw post
BPTB = bone-patellar tendon-bone graft.