Open versus arthroscopic anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials David M. Levy, MD, Brandon J. Erickson, MD and Bernard R. Bach, Jr, MD Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois ABSTRACT Background: The purpose of this paper was to determine if significant differences exist between open and arthroscopic anterior cruciate ligament reconstruction (ACLR). We have hypothesized that patients would experience less pain, fewer complications, and fewer reoperations after arthroscopic ACLR. Methods: A systematic review of multiple medical databases was performed. Randomized controlled trials with a minimum of 6 mo follow-up were included. Study quality was analyzed using the Modified Coleman Methodology Score (MCMS) and Jadad Scale. Results: Three studies met the inclusion criteria (212 subjects; 212 knees). The MCMS rating was fair at 60.7 ± 1.5, and the mean Jadad score was fair at 2.7 ± 1.5. One study reported long-term outcomes (mean 12 yr) of 53 patients (25 open, 28 arthro- scopic) and noted no differences in pain, strength, functional testing, or prevalence of osteoarthritis between groups. Two studies reported short-term outcomes of a combined 125 patients (58 open, 67 arthroscopic) with an average follow-up of 6 mo. In these studies, there were no differences in operative time, Lysholm scores, knee range of motion, laxity, complica- tions, or reoperations between groups. Immediate postoperative analgesic use was higher in the open group. Average thigh atrophy ranged from 1.5 to 2.8 cm in the open group and 1.4 to 1.5 cm in the arthroscopic group. Conclusions: Based on the examined studies, there are no differences in operative time, knee range of motion, laxity, Lysholm scores, complications, or reoperations between open and arthroscopic ACLR techniques. Immediate postoperative pain appears de- creased in patients undergoing arthroscopic ACLR. Key Words knee, anterior cruciate ligament reconstruction, arthroscopy, bone-patellar tendon-bone INTRODUCTION A nterior cruciate ligament (ACL) injuries are among the most common injuries sustained by athletes. 1,2 Ap- proximately 250,000 ACL injuries occur in the United States annually, with over half undergoing reconstruction (ACLR). 3,4 Currently, the majority of ACLRs are performed with a single-bundle graft through an arthroscopic approach using either a transtibial or anteromedial technique. 5 Results of these techniques have been favorable, even in high-level athletes. 6--8 However, open ACLR is still performed, and there have been very few studies analyzing the clinical differences between arthroscopic and open ACLR. 9 In retrospective studies, authors have claimed decreased incidence of patellar symptoms and knee stiffness as well as better range of motion and less need for manipulation with arthroscopic than with open ACLR. 10--12 But none of these studies have shown a difference in knee laxity when comparing the two techniques. Therefore, the purpose of this systematic review was to determine if a significant difference exists between open and arthroscopic anterior cruciate ligament reconstruction (ACLR) techniques in terms of operative time, postoperative pain, range of motion, knee laxity, complications, and reoperations. The authors hypothesized that there would be no significant differences between arthroscopic and open techniques in operative time, range of motion, and laxity. The authors also hypothesized that patients would experi- ence less postoperative pain, fewer complications, and a lower reoperation rate with arthroscopic ACLR when compared with open reconstruction. MATERIALS AND METHODS A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta- Analyses) guidelines. 13 Systematic review registration was performed using the Prospero International register of systematic reviews (registration number CRD42013005354). Because this Financial Disclosure: The authors report no conflicts of interest. Correspondence to David M. Levy, MD, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612 Tel: þ 1-847-641-0209; fax: þ 1-312-942-1517; e-mail: David_Levy@rush.edu. 1940-7041 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. ORIGINAL RESEARCH Volume 28  Number 5  September/October 2017 Current Orthopaedic Practice 449 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.