You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Anterolateral Knee Extra-articular Stabilizers: A Robotic Sectioning Study of the Anterolateral Ligament and Distal Iliotibial Band Kaplan Fibers
Abstract 1:
Background : The individual kinematic roles of the anterolateral ligament ( ALL ) and the distal iliotibial b and Kaplan fibers in the setting of anterior cruciate ligament ( ACL ) deficiency require further clarification . This will improve underst and ing of their potential contribution to residual anterolateral rotational laxity after ACL reconstruction and may influence selection of an anterolateral extra-articular reconstruction technique , which is currently a matter of debate . Hypothesis/ Purpose : To compare the role of the ALL and the Kaplan fibers in stabilizing the knee against tibial internal rotation , anterior tibial translation , and the pivot shift in ACL-deficient knees . We hypothesized that the Kaplan fibers would provide greater tibial internal rotation restraint than the ALL in ACL-deficient knees and that both structures would provide restraint against internal rotation during a simulated pivot-shift test . Study Design : Controlled laboratory study . Methods : Ten paired fresh-frozen cadaveric knees ( n = 20 ) were used to investigate the effect of sectioning the ALL and the Kaplan fibers in ACL-deficient knees with a 6 degrees of freedom robotic testing system . After ACL sectioning , sectioning was r and omly performed for the ALL and the Kaplan fibers . An established robotic testing protocol was utilized to assess knee kinematics when the specimens were subjected to a 5-N·m internal rotation torque ( 0 ° -90 ° at 15 ° increments ) , a simulated pivot shift with 10-N·m valgus and 5-N·m internal rotation torque ( 15 ° and 30 ° ) , and an 88-N anterior tibial load ( 30 ° and 90 ° ) . Results : Sectioning of the ACL led to significantly increased tibial internal rotation ( from 0 ° to 90 ° ) and anterior tibial translation ( 30 ° and 90 ° ) as compared with the intact state . Significantly increased internal rotation occurred with further sectioning of the ALL ( 15 ° -90 ° ) and Kaplan fibers ( 15 ° , 60 ° -90 ° ) . At higher flexion angles ( 60 ° -90 ° ) , sectioning the Kaplan fibers led to significantly greater internal rotation when compared with ALL sectioning . On simulated pivot-shift testing , ALL sectioning led to significantly increased internal rotation and anterior translation at 15 ° and 30 ° ; sectioning of the Kaplan fibers led to significantly increased tibial internal rotation at 15 ° and 30 ° and anterior translation at 15 ° . No significant difference was found when anterior tibial translation was compared between the ACL/ALL- and ACL/Kaplan fiber – deficient states on simulated pivot-shift testing or isolated anterior tibial load . Conclusion : The ALL and Kaplan fibers restrain internal rotation in the ACL-deficient knee . Sectioning the Kaplan fibers led to greater tibial internal rotation at higher flexion angles ( 60 ° -90 ° ) as compared with ALL sectioning . Additionally , the ALL and Kaplan fibers contribute to restraint of the pivot shift and anterior tibial translation in the ACL-deficient knee . Clinical Relevance : This study reports that the ALL and distal iliotibial b and Kaplan fibers restrain anterior tibial translation , internal rotation , and pivot shift in the ACL-deficient knee . Furthermore , sectioning the Kaplan fibers led to significantly greater tibial internal rotation when compared with ALL sectioning at high flexion angles . These results demonstrate increased rotational knee laxity with combined ACL and anterolateral extra-articular knee injuries and may allow surgeons to optimize the care of patients with this injury pattern


Title 2:
Anatomic Reconstruction of the Anterior Cruciate Ligament of the Knee With or Without Reconstruction of the Anterolateral Ligament: A Randomized Clinical Trial
Abstract 2:
Background : Rotational instability of the knee remains an issue after  anterior cruciate ligament ( ACL ) reconstruction .  Hypothesis/ Purpose : The purpose was to evaluate the subjective and objective outcomes of combined reconstruction of the ACL and anterolateral ligament ( ALL ) of the knee . The hypothesis was that favorable outcomes can be achieved with this surgical procedure compared with isolated anatomic reconstruction of the ACL . Study Design : R and omized controlled trial ; Level of evidence , 2 . Methods : One hundred ten patients with a unilateral ACL injury and high- grade pivot shift were r and omly assigned to undergo either combined ACL and ALL reconstruction ( group A ) or isolated ACL reconstruction  ( group B ) . Preoperative and postoperative evaluations of the patients were conducted by obtaining history details , recording physical examination findings , measuring knee laxity using the KT-1000 arthrometer , and using vali date d outcome scores for the knee . P < .05 was considered as the cut-off level of statistical significance . The Fisher exact and Mann-Whitney U tests were used to assess statistical significance . Results : At a mean follow-up of 27 months , 53 and 50 patients in groups A and B , respectively , were available for analysis . No statistically different outcomes were found between the 2 groups except for the KT-1000 arthrometer values . The median KT-1000 arthrometer result for combined ACL and ALL reconstruction was 1.3 mm , while the median result for isolated ACL reconstruction was 1.8 mm ( P < .001 ) . None of the patients ( n = 0 ; 0.0 % ) who underwent combined ACL and ALL reconstruction had anterior translation of greater than 5 mm at maximum pulling strength compared with their normal knees at final follow-up . On the other h and , 3 ( 6.0 % ) patients who underwent isolated ACL reconstruction had anterior translation of more than 5 mm . No serious complications were found in both groups . Conclusion : Combined ACL and ALL reconstruction was found to be effective in improving subjective and objective outcomes . Nevertheless , these findings were not significantly superior to isolated ACL reconstruction except for the instrumented knee laxity testing results . This might indicate that ALL reconstruction should not be performed routinely for patients undergoing ACL reconstruction


Title 3:
Combined Anatomic Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction.
Abstract 3:
PURPOSE The purpose of the current paper was to report the surgical technique of combined anatomic anterior cruciate ligament ( ACL ) and anterolateral ligament ( ALL ) reconstruction  as well as the short term clinical results after this surgical procedure . MATERIAL AND METHODS The current prospect i ve study included 32 patients ( 5 females and 27 males ) with combined ACL and ALL reconstruction performed between December 2015 and July 2016 . The patients were included in the study taking into consideration the following criteria : chronic ACL lesion , high grade rotational instability ( pivot shift grade II and III ) and participation in high grade pivoting sports . Patient evaluation followed an established clinical and imaging protocol both preoperatively and at 6 and 12 weeks postoperatively . This included  clinical knee stability testing ( Lachman test , Pivot shift test ) , Rolimeter differential laxity testing , subjective and objective IKDC scores and Lysholm score and Tegner score .  RESULTS Postoperative stability at 6 weeks and 12 weeks as tested with Lachman test ( p=0.02 and 0.01 , respectively ) , pivot shift test ( p=0.03 and 0.01 , respectively ) and the Rolimeter arthrometer ( p=0.008 and 0.006 , respectively ) showed a statistically significant difference as compared to preoperative values . Postoperative scores at 6 weeks and 12 weeks as measured using objective IKDC form ( p=0.008 and 0.006 , respectively ) , subjective IKDC form ( p=0.04 and 0.03 , respectively ) and Lysholm form ( p=0.02 and 0.01 , respectively ) were statistically significant improved as compared to preoperative values . All patients had a negative Lachman test at 6 and 12 weeks postoperatively . One patient had a positive grade I pivot shift test at 6 weeks postoperatively and two patients had a positive grade I pivot shift test at 12 weeks postoperatively . Differential anteroposterior laxity as measured with the Rolimeter arthrometer improved from 7.19±1.96 mm preoperatively to 0.28±0.45 mm and 0.13±0.34 mm , at 6 weeks and 12 weeks postoperatively , respectively . According to the objective IKDC form , 29 patients were normal or nearly normal ( grade A and B ) at 6 weeks postoperatively and 31 patients were normal or nearly normal at 12 weeks postoperatively . Subjective IKDC score improved from 47.72±17.18 preoperatively to 56.52±11.74 and 73.38±14.28 at 6 and 12 weeks postoperatively , respectively . Lysholm score improved from 63.44±23.01 preoperatively to 80.41±11.94 and 90.47±8.22 at 6 and 12 weeks postoperatively , respectively . Improved Tegner activity scores were present at 12 weeks postoperatively as compared with 6 weeks postoperatively , but still lower as compared to pre-traumatic scores . No significant complications were present in the current study group . CONCLUSIONS Combined ACL and ALL reconstruction is an effective surgical procedure , with improved postoperative clinical results and no significant short term complications . Longer follow-up is necessary in order to better evaluate the results of this procedure


Title 4:
Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society.
Abstract 4:
INTRODUCTION Lateral tenodesis ( LT ) is performed to limit the risk of iterative tear following anterior cruciate ligament ( ACL ) reconstruction in at-risk patients . By adding an extra procedure to isolated ACL graft , LT reconstruction increases operating time and may complicate postoperative course . The objective of the present study was to evaluate the rate of early complications . The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction . MATERIAL AND METHODS A prospect i ve multicenter study included 392 patients : 70 % male ; mean age , 29.9 years ; treated by associated ACL and LT reconstruction .  All adverse events were inventoried . RESULTS Mean hospital stay was 2 days , with 46 % day-surgery . Walking was resumed at a mean 27 days , with an advantage for patients treated by the hamstring technique . The early postoperative complications rate was 12 % , with 1.7 % specifically implicating LT reconstruction : pain , hematoma , stiffness in flexion and extension , and infection . There was a 5 % rate of surgical revision during the first year , predominantly comprising arthrolysis for extension deficit . The 1-year recurrence rate was 2.8 % . DISCUSSION The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction , with no increase in infection or stiffness rates . The rate of complications specific to ALL reconstruction was low , at 1.7 % , and mainly involved fixation error causing lateral soft-tissue impingement . LEVEL OF EVIDENCE IV , prospect i ve multicenter study
LET could lead to worse anterior instability than with ALL reconstruction when these two approaches were combined with single-bundle ACL reconstruction .
However , rotational stability and patient-reported outcomes were similar between the techniques