Failure of primary anterior cruciate ligament reconstruction (ACLR) leads to
revision surgeries which have higher cost burdens compared to the initial surgery. The most
common technical cause of primary ACLR failure is non-anatomic tunnel placement.
To investigate the effect of technology assisted ACLR on post-operative clinical
outcomes and tunnel placement compared to conventional arthroscopic ACLR.
Study Design: Systematic review of Level I-III studies and meta-analysis of Level I-II studies.
CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 2022.
Articles were included if there was intraoperative use of computer-assisted navigation (CAN),
robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers
searched, screened, and evaluated the included studies for data quality. Data was abstracted using
descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both
with 95% confidence intervals (CI), where appropriate.
Eleven studies were included with total 775 patients and majority male participants (70.7%).
Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775
patients). Three studies used fluoroscopic CAN (160 patients), one used intraoperative
fluoroscopy (60 patients), two used personalized 3D printed drill guides (119 patients), and five
used image-free CAN (454 patients).
Subjective IKDC scores increased in the technology assisted surgery (TAS) group (473 patients;
P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores
(447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI -
1.03 to 3.30) or negative pivot shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between
the two groups.
When using TAS, six (351 patients) of eight (451 patients) studies reported more accurate
femoral tunnel placement and six (321 patients) of ten (561 patients) studies reported more
accurate tibial tunnel placement in at least one measure. Four studies (342 patients) reported a
significant increase in operating time when using CAN (mean 152.7 min, 109 min, 86.9 min, 78 min)
versus conventional surgery (CS) (mean 119.7 min, 91 min, 59.1 min, 52 min). One 3DP study (41
patients) demonstrated a significant decrease in intraoperative positioning time of the tibial
tunnel (mean 3.3 min in TAS vs 5.9 min in CS) and the other (78 patients) demonstrated no
difference in operating time between the two groups. One study (209 patients) demonstrated
a significant increase in cost with use of CAN (mean 1158€) versus CS (mean 704€).
Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were
cited. There was no difference in adverse events between the two groups in studies that reported
Objective clinical outcomes do not differ between TAS and CS despite subjective outcomes
improving. CAN is more expensive and time consuming while 3DP is inexpensive and does not
lead to greater operating times. Despite improvements with TAS, tunnel placement data is difficult
to interpret due to heterogeneity between methods of measurement which may affect clinical outcomes.