Addition Of Lateral Extra-articular Tenodesis Research Articles

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis

Background: The addition of an iliotibial band–based lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to reduce failure rates. However, there are concerns as to the potential overconstraint of tibiofemoral kinematics that may increase the risk of cartilage degradation. To date, no clinical study has investigated the effect of LET on patellofemoral joint articular cartilage health. Hypothesis: It was hypothesized that at 2 years postoperatively, (1) the addition of LET at the time of ACLR would have no effect on cartilage health on magnetic resonance imaging (MRI), and (2) higher cartilage relaxation values would be associated with worse patient-reported and functional outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. Patients were randomized to either LET augmentation or not. Cartilage status in the patellofemoral joint between the ACLR group and ACLR+LET group was compared using 2-year postoperative quantitative MRI and the ACL osteoarthritis scores of both the surgical and the contralateral nonsurgical knees. Objective functional outcomes and patient-reported outcome measures (PROMs) were attained. Results: A total of 92 patients (43 patients in the ACLR group; mean age, 18.9 ± 3.2 years; 60.5% female; and 49 patients in the ACLR+LET group; mean age, 18.7 ± 3.2 years, 63.3% female) were included. No significant differences were seen in the mean values (ms) for adjusted T1ρ/T2 relaxation times in the medial patella (47.8/42.2 vs 47.3/43.2), central patella (45.5/42.5 vs 44.1/42.7), lateral patella (48.2/43.5 vs 47.3/43.0), medial trochlea (54.7/50.9 vs 56.4/50.9), central trochlea (53.3/51.1 vs 53.1/52.0), and lateral trochlea (54.9/52.1 vs 53.9/52.6) between the ACLR and ACLR+LET groups. No difference in overall ACL osteoarthritis scores was observed (P = .99). An increase in medial patellar T2 relaxation times was associated with a decreasing International Knee Documentation Committee score (P = .046), Knee injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale score (P = .01), and total KOOS (P = .01). Conclusion: There was no statistical difference in patellofemoral cartilage health between knees 2 years after primary ACLR with hamstring tendon autograft with or without LET. Statistically significant correlations were found between quantitative MRI relaxation times, functional outcome scores, and PROMs; however, the correlations were weak and the clinical significance is unknown. Registration: NCT02018354 (ClinicalTrials.gov identifier).

Association of Lateral Extra-Articular Tenodesis With Improved Graft Maturity on MRI 2 Years After ACL Reconstruction With Quadriceps Tendon Autograft in Skeletally Immature Athletes.

Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients. To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group. Cohort study; Level of evidence, 3. The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET. Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET. The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients.

Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons

Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.

The Effect of Lateral Extra-articular Tenodesis in an ACL-Reconstructed Knee With Partial Medial Meniscectomy: A Biomechanical Study

Background: Knee laxity increases with medial meniscectomy in anterior cruciate ligament (ACL)–reconstructed knees; however, the biomechanical effect of an additional lateral extra-articular tenodesis (LET) is unknown. Purpose/Hypothesis: The purpose of this study was to determine the kinematic effect of a LET in knees that underwent combined ACL reconstruction (ACL-R) and partial medial meniscus posterior horn (MMPH) meniscectomy. It was hypothesized that the addition of LET would reduce laxity in the ACL-reconstructed knee. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen human cadaveric knees (mean age, 41.5 years) were tested using a robotic system under 3 loads: (1) 89.0 N of anterior tibial (AT) load, (2) 5 N·m of internal rotation (IR) tibial torque, and (3) a simulated pivot shift—a combined valgus of 7 N·m and IR torque of 5 N·m—at 0°, 15°, 30°, 45°, 60°, and 90° of knee flexion. Kinematic data were acquired in 4 states: (1) intact, (2) ACL-R, (3) ACL-R + partial MMPH meniscectomy (MMPH), and (4) ACL-R + partial MMPH meniscectomy + LET (MMPH+LET). Results: In response to AT loading, there was a significant increase seen in AT translation (ATT) in the MMPH state at all knee flexion angles compared with the ACL-R state, with the highest increase at 90° of knee flexion (mean difference, 3.1 mm) (P < .001). Although there was a significant decrease in ATT at 15° of knee flexion with MMPH+LET (P = .022), no significant differences were found at other knee flexion angles (P > .05). In MMPH with IR torque, a significant increase was observed in IR at all knee flexion angles except 90° compared with the ACL-R state (range, 2.8°-4.9°), and this increase was significantly decreased at all flexion angles with the addition of LET (range, 0.7°-1.6°) (P < .05). Conclusion: Performing a partial MMPH meniscectomy increased ATT and IR in response to AT and IR loads compared with the isolated ACL-R state in a cadaveric model. However, when the LET procedure was performed after partial MMPH meniscectomy, a significant decrease was seen at all knee flexion angles except 90° in response to IR and torque, and a significant decrease was seen at 15° of knee flexion in response to AT load. Clinical Relevance: LET may be a useful adjunct procedure after ACL-R with partial MMPH meniscectomy to reduce knee laxity.

Revision ACL-R With Contralateral BTB Autograft and Iliotibial Band Lateral Extra-Articular Tenodesis With Interference Screw Fixation: A Technique Video

Background: Lateral extra-articular tenodesis (LET) is a reproducible and reliable technique to assist in control of rotational stability of the knee and decrease forces across an anterior cruciate ligament (ACL) graft in the setting of ACL reconstruction. Bone-tendon-bone (BTB) autograft is a common graft choice in revision ACL reconstruction. We present a technique for combining contralateral BTB autograft with LET in revision ACL reconstruction. Indications: This technique is indicated in patients undergoing ACL reconstruction who are at increased risk of graft failure, including revision cases, high-grade rotational instability, return to pivoting/cutting sports, ligamentous laxity, young age, meniscal deficiency, and hyperextension/recurvatum. Technique Description: The contralateral BTB autograft is harvested through standard fashion. We begin with the LET dissection prior to fluid infiltration in the soft tissues. A 1-cm strip of iliotibial (IT) band is harvested and whipstitched. The IT band strip is passed from anterior to posterior deep to the lateral collateral ligament (LCL). The LET socket is aimed 10° proximal and 10° anterior to limit tunnel convergence with the ACL. The LET is fixed with a tenodesis screw with the knee in neutral rotation and 30° of flexion. The ACL femoral socket is then placed, and care is taken to avoid convergence. A 10-mm tibial tunnel is drilled near the level of the posterior margin of the anterior horn of the lateral meniscus. The ACL is subsequently fixed with standard techniques. Results: The addition of LET to revision ACL has been shown to improve failure rate and outcomes. The use of contralateral patella tendon graft reduces morbidity on the operated leg. Notably, the position of the femoral LET tunnel is less important than the ACL tunnel position on the femur. If the LET is passed under the LCL, then the fixation point on femur becomes less relevant. The technique presented is a time-efficient way for combining tenodesis with revision ACL. Discussion/Conclusion: Performing a revision ACL reconstruction utilizing contralateral donor tissue with the addition of LET is a viable and reliable option for competitive athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation

Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk.

Paper 28: Both Hamstring Autograft Combined with Lateral Extra-Articular Tenodesis and Quadriceps Autograft Lead to Lower Graft Re-Tear Rates and Pivot Shift After ACL Reconstruction Compared to Hamstring Autograft Alone

Paper 28: Both Hamstring Autograft Combined with Lateral Extra-Articular Tenodesis and Quadriceps Autograft Lead to Lower Graft Re-Tear Rates and Pivot Shift After ACL Reconstruction Compared to Hamstring Autograft Alone

Poster 248: Lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction does not impact cartilage health in the patellofemoral joint based on post-operative two year qualitative and quantitative MRI analysis

Objectives: Lateral extra-articular tenodesis (LET) augmentation of anterior cruciate ligament reconstruction (ACLR) has been shown in multiple clinical and biomechanics studies to be an effective procedure to control rotational laxity, reducing failure rates. However, it is uncertain whether augmentation with an iliotibial band based LET may cause increased contact pressure in the patellofemoral joint (PFJ), resulting in cartilage damage. The purpose of the current study was to assess PFJ cartilage status in patients that underwent ACLR with or without LET augmentation using magnetic resonance imaging (MRI). It was hypothesized that 1) the addition of LET at the time of ACLR would have no effect on cartilage health on post-operative two-year MRI; 2) higher cartilage relaxation values would be associated with worse patient reported and functional outcomes at two years post-operatively. Methods: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. The patients were randomized either to receive LET augmentation (modified Lemaire technique) or not. Cartilage status in the PFJ between ACLR alone group and ACLR+LET group were compared by quantitative MRI (qMRI) analysis of T2 and T1 rho sequences (figure 1), and qualitative assessment by ACL osteoarthritis score (ACLOAS) on post-operative two year MRI for surgical and contralateral non-surgical knees. Objective functional outcomes (range of motion (ROM), hop test and isokinetic strength) and patient reported outcome measures including Knee injury Osteoarthritis and Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score were attained. Descriptive statistics were calculated for each group using means and standard deviations (SD) for continuous variables and proportions for categorical variables. ANCOVA was used to determine the adjusted mean difference in T1rho and T2 relaxation times between groups for each compartment in the patella and trochlea. Spearman’s rho was used to assess the correlation between relaxation times within each compartment and patient-reported and functional outcomes at two-years postoperative. Statistical significance was set at P = 0.05. Results: Ninety-two patients (43 patients in ACLR group, mean age (±SD) 18.9±3.2 years, 60.5% female, and 49 patients in ACLR+LET group, 18.7±3.2 years, 63.3% females) were included. No significant differences were seen in patient background, meniscal treatment and cartilage status at the time of surgery (table 1). No significant differences were seen in the mean values (milliseconds) for qMRI for adjusted T1 rho relaxation times in the medial patella (MP) (47.8 vs 47.3), central patella (CP) (45.5 vs 44.1), and lateral patella (LP) (48.2 vs 47.3), and medial trochlea (MT) (54.7 vs 56.4), central trochlea (CT) (53.3 vs 53.1), and lateral trochlea (LT) (54.9 vs 53.9), and adjusted T2 relaxation times in MP (42.2 vs 43.2), CP (42.5 vs 42.7), LP (43.5 vs 43.0), MT (50.9 vs 50.9), CT (51.1 vs 52.0), LT (52.1 vs 52.6) between ACLR and ACLR+LET groups. Similarly, no difference in ACLOAS scores (overall score 10 vs 11, p = 0.99) were observed. An increase in medial patellar T2 relaxation times were associated with decreasing IKDC score (p = 0.046), KOOS symptoms subscale (p = 0.01), and total KOOS score (p = 0.01). Increasing limb symmetry on the hop test was associated with increasing T1ρ (p = 0.04) and T2 (p = 0.01) relaxation in the lateral trochlea Conclusions: No difference was found in patellofemoral cartilage health between knees undergoing primary ACLR with hamstring tendon autograft with or without LET at two years post-operative. Statistically significant correlations were found between qMRI relaxation times and functional outcome scores and PROMs, however the correlations were weak and the clinical significance of these changes are undetermined. [Table: see text]

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P= .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P= .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P= .001). At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. Level I, randomized controlled trial.

The Role of Lateral Extra-articular Tenodesis in Anterior Cruciate Ligament Reconstruction and Treatment of Rotatory Knee Instability: a Scoping Review.

The addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has become increasingly popular to address residual rotatory knee instability. The purpose of this article is to review the anatomy and biomechanics of the anterolateral complex (ALC) of the knee, outline different LET techniques, and provide biomechanical and clinical evidence for its use as an augmentation procedure with ACLR. Rotatory knee instability has been identified as a common contributor to ACL rupture in both the primary and revision settings. Several biomechanical studies have shown that LET reduces strain on the ACL by decreasing excess tibial translation and rotation. Additionally, in vivo studies have demonstrated restoration of side-to-side differences in anterior-posterior knee translation, higher rates of return to play, and overall increased patient satisfaction following combined ACLR and LET. As a result, various LET techniques have been developed to help offload the ACL graft and lateral compartment of the knee. However, conclusions are limited by a lack of concrete indications and contraindications for use of LET in the clinical setting. Recent studies have shown that rotatory knee instability contributes to native ACL and ACL graft rupture and LET may provide further stability to reduce rates of failure. Further investigation is needed to establish concrete indications and contraindications to determine which patients would most benefit from added stability of the ALC.

No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction – Results from the stability randomized trial

ObjectivesResults from the Stability Study suggest that adding a lateral extra-articular tenodesis (LET) to a hamstring tendon autograft reduces the rate of anterior cruciate ligament reconstruction (ACLR) failure in high-risk patients. The purpose of this study is to report adverse events over the 2-year follow-up period and compare groups (ACLR alone vs. ACLR + LET). MethodsStability is a randomized clinical trial comparing hamstring tendon ACLR with and without LET. Patients aged 14–25 years with an ACL deficient knee were included. Patients were followed and adverse events documented (type, actions taken, resolution) with visits at 3, 6, 12, and 24 months postoperatively. Adverse events were categorized as none, minor medical, minor surgical, contralateral ACL rupture, or graft rupture. Patient reported outcome measures (PROMs) collected at each visit included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score (IKDC), and ACL Quality of Life Questionnaire (ACL-QOL). ResultsIn total, 618 patients were randomized (mean age 18.9 years, 302 (49%) male). Forty-five patients (7%) suffered graft rupture; 34 (11%) in the ACLR group compared to 11 (4%) in the ACLR + LET group (RRR = 0.67, 95% CI 0.36 to 0.83, p < 0.001). There were no differences in effusion or infection rates between groups. The ACLR + LET group experienced an increased number of hardware removals (10 vs. 4). Overall, the rate of minor medical events (11%), minor surgical events (7%), and ipsilateral or contralateral ACL tears (10%) were low considering the high-risk patient profile. Increasing severity of adverse events was associated with lower PROMs at 24 months post-operative. Patients in the ACLR + LET group reported greater degree of pain at 3 months only. There were no clinically significant differences in range of motion between groups. ConclusionsThe addition of LET to hamstring tendon autograft ACLR in young patients at high risk of re-injury resulted in a statistically significant reduction in graft rupture. While the addition of LET may increase rates of hardware irritation, there was no significant increase in overall rates of minor medical adverse events, minor surgical events, or overall re-operation rates. The concerns regarding complications associated with a LET did not materialize in this study. Level of evidenceLevel I

Adding a Lateral Extraarticular tenodesis to ACL Reconstruction in 2022

Lateral extra-articular tenodesis (LET) is a procedure used to control anterolateral rotatory laxity. It was first described to treat the ACL deficient knee prior to advent of intra-articular reconstruction. The aim was adding a lateral soft tissue restraint away from the central pivot of the knee to improve rotational control. The recent evidence from the STABILITY RCT has shown that the addition of LET to hamstring autograft ACLR in young patients (14-25 years ) results in clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years postoperatively. This has subsequently been verified by various authors that adding a lateral soft tissue restraint to an intraarticular ACL reconstruction reduced both primary and revision ACL graft failures. The current indication for adding an LET to ACL surgery are : in high grade knee laxity in clinic detected on physical examination, patients with joint laxity, chronic ACL injuries, athletes returning to pivot sports after surgery and in revision ACL cases.

A Case Series of Successful Lateral Extra-articular Tenodesis (LET) in ACL Reconstruction

Introduction: In the United States, 80.000-100.000 Anterior Cruciate Ligament (ACL) injury repairs are performed annually. Recent development added lateral extra-articular tenodesis (LET) to improve the outcome of ACL reconstruction. This research evaluates the outcome of LET in ACL injury based on our experiences evaluated in effectiveness and complication. Methods: This case series included three patients diagnosed with ACL rupture in Cipto Mangunkusumo General Hospital from January to February 2022. All patients underwent ACL reconstruction followed by LET. Results: In our studies, all of our cases underwent surgery with successful clinical outcomes. In addition, all patients in our studies also reported no complications postoperatively. Conclusion: The addition of LET in ACL reconstruction was found to be successful with no complications. Further application of the method is endorsed to bring more benefits with less risk of side effects or failure. Follow-up should be done to observe the long-term effects of the method.

Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes

Background: There is growing evidence that anterolateral procedures can reduce the risk of rerupture in high-risk recreational athletes undergoing primary anterior cruciate ligament (ACL) reconstruction (ACLR). However, this effectiveness has never been evaluated in elite athletes. Purpose: The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis (LET) in reducing revision rates in primary ACLR in elite athletes. Additionally, this study evaluated whether LET had a greater effect when combined with ACLR utilizing a hamstring or patellar tendon graft. Study Design: Cohort study; Level of evidence, 3. Methods: A consecutive cohort of elite athletes with an isolated ACL tear undergoing autograft patellar or hamstring tendon reconstruction with or without Lemaire LET were analyzed between 2005 and 2018. A minimum 2-year follow-up was required. The association between the use of LET and ACL graft failure as defined by revision ACLR was evaluated with univariate and multivariate logistic regression models. Results: A total of 455 elite athletes (83% men and overall age 22.5 ± 4.7 years) underwent primary ACLR with (n = 117) or without (n = 338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure, including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACLR reduced the risk of graft failure by 2.8 times, with 16.5 athletes needing LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (relative risk = 0.325; P = .029) as compared with ACLR alone after controlling for sex and age at ACLR. Including graft type in the model did not significantly change the risk profile, and although a patellar tendon graft had a slightly lower risk of failure, this was not statistically significant (P = .466). Conclusion: The addition of LET reduced the risk of undergoing revision by 2.8 times in elite athletes undergoing primary ACLR. This risk reduction did not differ significantly between the patellar tendon and hamstring tendon autografts. With these results, status as an elite athlete should be included in the indications for a LET, as they are at increased risk for ACL graft failure.

Isolated ACL Reconstruction Versus ACL Reconstruction Combined With Lateral Extra-articular Tenodesis: A Comparative Study of Clinical Outcomes in Adolescent Patients

Background: Young patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) are at a particularly high risk of graft ruptures compared with adults. Recent studies have demonstrated significant reductions in ACL graft rupture rates in high-risk adult populations when a lateral extra-articular procedure is performed, but comparative studies in pediatric and adolescent populations are currently lacking in the literature. Purpose/Hypothesis: The purpose of this study was to compare the clinical outcomes of isolated ACLR versus combined ACLR and lateral extra-articular tenodesis (LET) when using the Arnold-Coker modification of the MacIntosh procedure in early adolescent patients. The hypothesis was that combined procedures would be associated with a significantly reduced risk of graft ruptures. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of consecutive early adolescent patients who underwent ACLR using a hamstring tendon autograft with or without the Arnold-Coker modification of the MacIntosh procedure was conducted. Patients with ≥1 additional risk factors for a graft rupture were offered LET in addition to ACLR (pivot-shift grade 2 or 3, high level of sporting activity defined as Tegner activity score ≥7, participation in pivoting sports, and Segond fractures). Clinical outcomes including graft rupture rates, patient-reported outcome measure scores (Knee injury and Osteoarthritis Outcome Score and subjective International Knee Documentation Committee), knee stability, return-to-sports rates, reoperation rates, and complications were assessed. Comparisons between variables were assessed with the chi-square or Fisher exact test for categorical variables and the Student or Wilcoxon test for quantitative variables. Multivariate analyses were undertaken to evaluate risk factors for a graft rupture. Results: A total of 111 patients with a mean follow-up of 43.8 ± 17.6 months (range, 24-89 months) were included in the study; 40 patients underwent isolated ACLR, and 71 underwent ACLR + LET. The addition of LET to ACLR was associated with a significantly lower graft rupture rate compared with isolated ACLR (0.0% vs 15.0%, respectively; odds ratio, 15.91 [95% CI, 1.81-139.44]; P = .012). It was also associated with significantly better knee stability (pivot-shift grade 3: 0.0% vs 11.4%, respectively; P = .021) (side-to-side anteroposterior laxity difference >5 mm: 0.0% vs 17.1%, respectively; P = .003) and Tegner activity scores (7 vs 6, respectively; P = .010). There were no significant differences between the groups regarding the Patient Acceptable Symptom State for the patient-reported outcome measures, nor for any of the other outcome measures evaluated, and no differences in the rate of non–graft rupture related reoperations or complications. The ACLR + LET group exceeded the minimal clinically important difference with respect to the Tegner activity scale. Conclusion: In a retrospective comparative cohort study of adolescents, combined ACLR and LET was associated with a significantly lower graft rupture rate and no difference in non–graft rupture related reoperations or complications compared with isolated ACLR.

Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review.

Background:Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique.Purpose:To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI).Study Design:Narrative review.Methods:In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist.Results:The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients.Conclusion:As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.

Biomechanical Analysis of Tibial Motion and ACL Graft Forces After ACLR with and without let at Varying Tibial Slopes

Background:Lateral extra-articular tenodesis (LET) is being performed with increasing frequency in the setting of anterior cruciate ligament reconstruction (ACLR) as a way to decrease rotational instability and graft failure rates, especially in young, active patients. The degree of posterior tibial slope has been shown to affect ACL graft failure rates.1 The effect of LET plus ACLRs on tibial motion and graft forces in the setting of varying tibial slopes has not been elucidated.Hypothesis/Purpose:LET will decrease tibial translation, tibial rotation, and ACL graft forces compared to ACLR alone with increasing tibial slope throughout knee range of motion.Methods:Twelve cadaveric knees (40.5 mean age, all female) were tested in 4 conditions (1: intact; 2: ACLR; 3: ACLR + LET; and 4: ACL cut) with varying posterior tibial slopes (5°, 10°, 15°, and 20°) at three flexion angles (0°, 30, ° and 60°). Specimens were mounted to a load frame which applied a 500-N axial load with 1 N-M of internal rotation torque (Figure 1). The amount of tibial translation was measured using a laser sensor and rotation was measured along the axis of the load frame. ACL graft forces were measured via a force transducer.Results:No clinically relevant difference was found in graft force (all differences <6.8 N, except the 5° posterior tibial slope at 30° of flexion showing a 12.1 N reduction with LET), anterior tibial translation (all differences <2.4 mm), or internal rotation (all differences < 1.59°). Compared to the intact state, the cut ACL state had higher anterior tibial translation (maximum increase +9.1 mm at slope 20°, Flexion 60°) and internal rotation (maximum increase +4.3° at slope 5°, flexion 30°). Higher ACL graft forces were observed with increasing posterior tibial slope (ACLR graft force at 0° of flexion was 81.6 N at 5°, 97.8 N at 10°, 107.0 N at 15°, 113.9 N at 20° of slope). Figure 2 shows ACL graft forces in N, Figure 3 shows anterior tibial translation in mm and Figure 4 shows internal rotation in degrees. All figures present data at 30°of flexion.Conclusion:No clinically relevant difference was shown with the addition of LET in the setting of ACLR for patients with posterior tibial slopes from 5° to 20° at flexion angles of 0°, 30°, and 60° in regards to graft force, anterior tibial translation, and internal tibial rotation under a 500 N compressive load.Figure 1.AP and Posteromedial views of the testing specimen mounted on load frameFigure 2.ACL Graft Force at 500N compression at Flexion 30° for ACLR (Red) vs ACLR+LET (Blue) states at varying posterior tibial slopes (5°, 10°, 15°, and 20°)Figure 3.Anterior Tibial Translation at Flexion 30° for all states (Intact (blue), ACLR+LET (red), ACLR (green), ACL cut (orange)) at varying posterior tibial slopes (5°, 10°, 15°, and 20°)Figure 4.Internal Tibial Rotation at Flexion 30° for all states (Intact (blue), ACLR+LET (red), ACLR (green), ACL cut (orange)) at varying posterior tibial slopes (5°, 10°, 15°, and 20°)Reference:1. Bernhardson AS, Aman ZS, Dornan GJ, et al. Tibial Slope and Its Effect on Force in Anterior Cruciate Ligament Grafts: Anterior Cruciate Ligament Force Increases Linearly as Posterior Tibial Slope Increases. Am J Sports Med. 2019;47(2):296-302. doi:10.1177/0363546518820302

Anterior cruciate ligament reconstruction with lateral extra-articular tenodesis reduces knee rotation laxity and graft failure rate: A systematic review and meta-analysis.

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) reduces rotational laxity of the knee, and to compare the clinical results of this treatment with those of ACLR alone. PubMed, Embase, and Cochrane Library were searched by two researchers for clinical studies comparing ACLR with and without LET. Studies with only evidence levels I and II and studies in which anterior lateral ligament reconstruction was performed with grafts were excluded. The risk of bias of the studies was assessed using the Cochrane risk-of-bias and modified Downs & Black tools. The outcomes included (1) functional outcomes; (2) knee laxity measures; (3) knee injury osteoarthritis and outcome score; and (4) complications. The outcomes of the two groups were extracted, summarized and compared. A total of 234 studies were retrieved and 223 were excluded. Eleven clinical studies with 1745 patients were included in our meta-analysis. Compared to the patients who underwent ACLR alone, the patients who underwent ACLR with LET had reduced pivot-shift (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.31 to 0.74, p = 0.0009), and lower graft failure rate (OR 0.34, 95% CI 0.20 to 0.55, p < 0.0001). Compared with ACLR only, ACLR combined with LET can effectively reduce rotation laxity of the knee joint, and reduce the graft failure rate in high-risk patients. However, the effects on the function and activity level of patients cannot be confirmed.

Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers.

Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates. A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7months, p = 0.005), recurrent effusions (11.4 vs 10.2months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5months. Patients under 25years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation. Level IV.

Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft

Background: Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined. Purpose/Hypothesis: The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified. Study Design: Cohort study; Level of evidence, 3. Methods: The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft. Results: The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369). Conclusion: At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.