Old versus new guideline (2011 versus 2018)

For the previous guideline, the EBRO (Evidence Based Richtlijn Ontwikkeling) method was used to develop the modules. The current guideline has been drafted in accordance with the requirements outlined in the “Guidelines 2.0” report of the Guideline Advisory Committee of the Council on Science, Education and Quality (WOK). The level of scientific evidence was determined using the GRADE (Grading Recommendations Assessment, Development and Evaluation) method.

 

In this appendix, the difference between the old and new guideline will be explained for the chapters in question.

 

Indicatie VKB (Indication for ACL)

In the previous guideline, two different questions were included considering the indication for ACL reconstruction 1) Wat zijn de relevante parameters van invloed op de indicatie voor voorste kruisbandreconstructie (What are the relevant parameters that affect the indication for anterior cruciate ligament reconstruction?; 2) Welke klachten of bevindingen zijn voorspellend voor een slecht resultaat van de behandeling van een kruisbandletsel (Which symptoms or findings have a predictive value for a poor result of the treatment of an anterior cruciate ligament injury?). We decided to combine these questions in one question concerning the indication in ACL injured patients. Thereby, the text of the previous guideline was revised.

 

Optimale timing (Optimal timing)

In the previous guideline, the literature analysis was based on a systematic review by Smith et al. (2010). Both randomised and non-randomised studies were included in this review, whereby no differentiation was made between study designs in the analysis. The results of the studies were only reported as meta-analysis and could therefore not be subtracted for studies separately from the review. Andernord (2013) also included both randomised and non-randomised studies, but in their literature analysis a distinction was made in study design, which enables us to use the results of the RCTs only and exclude the non-randomised studies. Therefore, the literature analysis was based on the systematic review by Andernord.

 

Type graft (Type of graft)

Hamstring autograft versus BPTB autograft: The articles referenced in the old guideline could not be updated. Five meta-analyses included not only RCTs or comparative studies, three meta-analyses did not evaluate the risk of bias and one meta-analysis only included RCT for which individual patient data was available.

 

Autograft versus allograft: The meta-analyses previously referenced are not applicable to this update. Two meta-analyses included not only RCTs and one meta-analysis focused on the comparison between 4HS and BPTB.

 

Single bundle versus double bundle: The systematic review previously referenced did not only include RCTs and did not specify any selection criteria regarding the length of follow-up. Furthermore, two of the referenced RCTs were in fact not an RCT and will be excluded from further analyses. Only two of the described RCTs had sufficiently long enough follow-up (i.e. two years), namely Streich (2008) and Aglietti (2010). These RCTs were included in the review by Zhu (2013).

 

Fixation techniques: The fixation technique strongly depends on the used graft. Because of the variety in techniques and heterogeneity of published studies no conclusions and recommendations could be given about ACL graft fixation in this guideline.