title: Closure of patellar tendon defect in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: systematic review of randomized controlled trials.
abstract: OBJECTIVE
  This study aimed to systematically review the highest level of evidence on anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts with patellar tendon defect closure versus no closure after surgery.
  
  
  METHODS
  We performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Level I and Level II randomized controlled trials comparing patellar tendon defect closure to no closure during ACL reconstruction with BPTB autografts were included. Two independent reviewers analyzed all studies. Descriptive statistics were calculated. Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS) and Jadad scale.
  
  
  RESULTS
  Four studies with a combined 221 patients (154 male patients and 67 female patients) with an average age of 26.6 ± 2.4 years (range, 17 to 54 years) were included. All studies randomized patients before surgery into ACLR with BPTB autografts either with patellar tendon defect closure or without closure. There were no differences in clinical outcomes (Lysholm score, Tegner scale, International Knee Documentation Committee [IKDC] classification, modified Larsen score, and Lauridsen rating) between groups. There were no significant differences in knee pain between groups. All studies reported imaging findings of the patellar tendon defect, with 2 studies showing no difference in appearance between groups, one study showing excessive scar formation with defect repair, and one study showing improved restoration of normal tendon appearance with defect repair. The overall quality of the studies was poor, with all studies scoring less than 46 (average, 40.5 ± 4.7) on the MCMS and scoring 1 on the Jadad scale.
  
  
  CONCLUSIONS
  Based on this systematic review of 4 randomized trials, there are no statistically significant or clinically relevant differences in outcomes between patients who have the patellar tendon defect closed and those who have it left open after ACLR with BPTB autografts. The methodology of the included studies limits the interpretation of the data, as evidenced by low MCMS and Jadad scores.
  
  
  METHODS
  Level II, systematic review of Level I and Level II studies.
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address: rmfrank3@gmail.com.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Frank
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Randy
authors.initials: R
authors.lastname: Mascarenhas
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Marc
authors.initials: M
authors.lastname: Haro
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Nikhil N
authors.initials: NN
authors.lastname: Verma
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Cole
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Bush-Joseph
authors.affiliation: Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bach
mesh_terms: D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D064592:Autografts; D050376:Bone-Patellar Tendon-Bone Grafting; D064594:Bone-Patellar Tendon-Bone Grafts; D006801:Humans; D007719:Knee Joint / Q000601:surgery*; D017847:Patellar Ligament / Q000601:surgery*; D016032:Randomized Controlled Trials as Topic; D014182:Transplantation, Autologous