Anterior cruciate ligament reconstruction using peroneus longus with lateral extra-articular tenodesis has excellent functional outcomes with a high return to sport rate: A prospective cohort study of 482 patients over 2years.

Residual anterior knee laxity following anterior cruciate ligament reconstruction (ACLR) has been associated with inferior subjective outcomes and an increased risk of revision surgery; however, its prognostic value for predicting subsequent graft re-rupture remains unclear. This study aimed to assess the association between KT-1000-measured 1-year post-operative anterior knee laxity and graft re-rupture after ACLR. We hypothesised that increased residual anterior knee laxity at 1 year post-operatively would be associated with a higher risk of graft re-rupture in a dose-dependent manner. This retrospective cohort study included 1011 amateur and professional athletes who underwent primary ACLR with hamstring tendon autograft (HTA) between 2005 and 2024 by a single surgeon using a standardised surgical technique. Patients undergoing revision ACLR, multiligament reconstruction, or any lateral extra-articular augmentation procedure were excluded. Anterior knee laxity was quantified using the KT-1000 arthrometer at a mean of 12.1 ± 1.3 months post-operatively. A landmark time-to-event design was applied, with follow-up starting from the KT-1000 assessment to minimise immortal time bias and to focus on anterior knee laxity after biological graft maturation. The primary exposure was KT-1000 side-to-side difference (SSD), analysed as both a continuous variable and using clinically relevant thresholds (<3 mm, 3-5 mm, and >5 mm). Associations between post-operative laxity and graft re-rupture, adjusting for demographic, surgical, and activity-related factors were assessed using a multivariable Cox proportional hazards model. Secondary analyses evaluated the relationship between KT-1000 laxity, return-to-play status, and post-operative activity level. Patients who experienced graft re-rupture had significantly greater post-operative KT-1000 SSD compared with those without re-rupture (3.5 ± 1.3 mm vs. 2.1 ± 0.9 mm; p < 0.001). Increased KT-1000 SSD was independently associated with higher graft re-rupture risk (adjusted hazard ratio, 2.97 per 1-mm increase; 95% confidence interval [CI], 2.5-3.5). Higher laxity categories were associated with progressively increased re-rupture risk with adjusted hazard ratios of 1.76 (95% CI, 1.3-2.3; p < 0.001) for 3-5 mm and 8.85 (95% CI, 4.7-16.4; p < 0.001) for >5 mm compared with <3 mm. Post-operative 1-year KT-1000 anterior knee laxity was not significantly associated with return-to-play status (odds ratio, 0.84 per 1-mm increase; 95% CI, 0.6-1.1; p = 0.28), but was modestly associated with lower post-operative Tegner activity level (p < 0.001). KT-1000-measured post-operative anterior knee laxity at 1 year post-operatively was independently associated with the risk of subsequent graft re-rupture after HTA ACLR in athletic patients. These findings suggest that residual laxity may serve as a useful risk stratification tool, rather than a deterministic predictor of failure, and should be interpreted in the context of overall clinical and biomechanical assessment. Level III.

Lateral Extra-Articular Procedures Reduce Anterior Cruciate Ligament Graft Failure in Patients Younger than 21 Years Undergoing Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Primary Anterior Cruciate Ligament Repair for Acute Proximal Tears Shows High Return to Sport and a 10% Failure Rate at a Minimum 2-Year Follow-Up.

Editorial Commentary: Cost-Effective, Until It Isn't: Variability in Lateral Extra-articular Tenodesis Techniques Challenges Cost Analyses for Primary Anterior Cruciate Ligament Reconstruction.

Optimizing tunnel placement for lateral extra-articular procedures in pediatric epiphyseal anterior cruciate ligament reconstruction: a three-dimensional simulation study of physeal damage and safe zone identification.

Editorial Commentary: Look Out for Internal Rotational Tibial Subluxation on Magnetic Resonance Imaging as an Indicator of High-Grade Rotatory Instability in Anterior Cruciate Ligament-Deficient Knees.

Editorial Commentary: LET's Keep Expanding Our Indications for Lateral Extra-articular Procedures During Anterior Cruciate Ligament Reconstruction.

Time-zero quantitative pivot-shift after combined anterior cruciate ligament and anterolateral ligament reconstruction in pivot-shift grade 2-3 knees: single- versus double-bundle hamstring anterior cruciate ligament reconstruction.

Surgeon-perceived risk factors for revision after anterior cruciate ligament reconstruction show global agreement with regional differences.

Editorial Commentary: Useful Considerations When Adding Lateral Extra-articular Procedures to Augment Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients.

To compare clinical and radiological outcomes of anterior cruciate ligament reconstruction (ACLR) using non-detached hamstring tendon (NDHT) versus conventional detached hamstring tendon (DHT) technique. Embase, PubMed, Ovid Medline and CINAHL databases were searched from inception to October 2025. Inclusion criteria included comparative studies of clinical or radiographic outcomes between NDHT and DHT. Studies were excluded if they were non-comparative or if they involved extra-articular procedures. The primary outcome was the post-operative International Knee Documentation Committee (IKDC) score. Secondary outcomes included Lysholm, Tegner, KT-1000 (knee testing 1000 [laxity arthrometer]) scores, rate of return-to-sport (RTS), retear rate and graft maturation. Data were pooled using random-effects models with significance set at p < 0.05. Sensitivity analyses included randomized trials only. A total of 11 studies (n = 731; 354 NDHT, 377 DHT patients) met inclusion criteria. IKDC scores at ≥12 months (mean difference [MD] = 0.67, 95% confidence interval [CI]: -2.67 to 3.94, p = 0.69), Lysholm scores at ≥6 months (MD = -1.02, 95% CI: -2.52 to 0.49, p = 0.19), Tegner scores at ≥6 months (MD = 0.18, 95% CI: -0.19 to 0.55, p = 0.34), KT-1000 arthrometer at ≥24 months (MD = -0.29, 95% CI: -0.67 to 0.30, p = 0.14), RTS rates at ≥12 months (risk ratio [RR] = 1.00, 95% CI: 0.94 to 1.07, p = 0.89) and retear rates at ≥12 months (RR = 0.63, 95% CI: 0.17 to 2.40, p = 0.50). None of these findings changed in sensitivity analysis. The NDHT demonstrated significantly better graft maturation at 6 and 12 months (p < 0.05), but these differences disappeared by 24 months. Preserving the tibial insertion of the hamstring graft in ACLR (NDHT) resulted in comparable clinical outcomes to those of the detached technique (DHT), with no significant differences observed between the two approaches. Future studies should assess potential cost and time benefits of NDHT. Level IV.

Higher body mass index, postoperative bracing, narrower femoral notch, and anterior tibial tunnel positioning are independent risk factors for cyclops syndrome following anterior cruciate ligament reconstruction.

Background:Multiple clinical studies have highlighted the improved outcomes of ACLR in associated with LEAPs. However, such procedures are associated with increased costs and operating room time, thus questioning their cost-effectiveness.Purpose:To evaluate the cost-effectiveness of augmenting an anterior cruciate ligament reconstruction (ACLR) with autograft lateral extra-articular procedures (LEAP), either a modified Lemaire or anterolateral ligament reconstruction.Study Design:Economic and decision analysis; Level of evidence, 3.Methods:A cost-effectiveness analysis was developed using failure rates for ACLR with and without concomitant autograft LEAPs from existing level 1 and 2 studies. Institutional data were used to estimate costs, including hospital and surgeon fees for ACLR and additional implant costs for LEAP. Utility measures were derived by linear approximation of the European Quality of Life 5 Dimension from the Knee injury and Osteoarthritis Outcome Score to evaluate improvements in quality-adjusted life years (QALY), a standardized metric that combines quantity and quality of life into a single value, over 1 year. Cost-effectiveness was determined based on previous literature, with an intervention considered cost-effective if the incremental cost-effectiveness ratio (ICER) was <$50,000/QALY. Three 1-way sensitivity analyses were conducted to assess the effect of implant cost, LEAP failure rates, and surgical time on cost-effectiveness.Results:The total cost of an isolated ACLR was estimated at $14,000, increasing to $14,990 with LEAP augmentation. Cost-effectiveness analysis showed an ICER of $25,313/QALY with LEAP augmentation, remaining below the $50,000/QALY cost-effectiveness threshold. Implant costs could rise to $1265 while maintaining cost-effectiveness, given an LEAP operation time (OR) of 15 minutes. Additionally, the failure rate of LEAP-augmented ACLR could increase from 2.9% to 7.7% while still meeting cost-effectiveness criteria. Finally, time sensitivity analysis indicated that for the procedure to remain cost-effective, the maximum allowable additional operative time is 36 minutes, given an OR cost of $46/minute.Conclusion:Although LEAP increases the time and cost of ACLR, it remains a cost-effective strategy for patients who are suitable candidates for augmentation.

The purpose of this systematic review was to evaluate the clinical and patient-reported outcomes of an isolated lateral extra-articular procedure (LEAP) performed to address persistent rotatory instability following a previous isolated anterior cruciate ligament reconstruction (ACLR) in the absence of complete graft rupture. A literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on an isolated LEAP performed to address instability after a standalone ACLR, without a complete graft tear, were included. Pre-operative factors analysed included time from index ACLR, graft type, graft status and tunnel position, associated meniscal tears and grade of pivot shift. Pre- and post-operative patient-reported outcome measures (PROMs), and post-operative clinical outcomes (including the grade of residual pivot shift) were also analysed. The rate of subsequent complete graft rupture or persisting instability was noted. Five studies with a total of 74 knees were included. These comprised 42 males and 32 females with an age range of 17-41 years and mean follow-up of 25.5 ± 6.9 (12-30) months. There was a statistically significant improvement in pivot shift grade distribution from pre-operative (27 Grade 1, 16 Grade 2 and 9 Grade 3) to post-operative (8 Grade 1, 0 Grade 2 and 0 Grade 3) (χ2 test, p < 0.001). A random effects meta-analysis showed a statistically significant improvement between pre- and post-operative values for International Knee Documentation Committee (IKDC), Lysholm and Tegner Activity Scores. The pooled rate of complete graft rupture or persisting instability was 5.4% (0%-10.5%). An isolated LEAP is an effective procedure with good clinical and patient-reported outcomes and low failure rates for patients with persisting rotatory instability after a previous ACL reconstruction. Level IV.

Anterior cruciate ligament reconstruction (ACLR) is commonly performed in the younger or active population, but failure rates have been disappointing in high-risk patients. Recently, lateral extra-articular procedures such as the modified Lemaire extra-articular tenodesis (LET) have been proposed to decrease failure rates, but knowledge on short-term rehabilitation, stiffness, and isokinetic strength is limited. This study aimed to assess the short-term patient-reported outcome measures (PROMs) and physical performance outcomes following ACLR with and without LET. A prospective study was performed among 152 patients aged ≤25 years undergoing hamstring autograft ACLR with or without modified Lemaire LET between 2019 and 2022 with minimum 1-year follow-up. PROMs (Tegner, International Knee Documentation Committee, Lysholm, NRS for pain, and EQ-5D) were compared between groups preoperatively and at 3, 6, 9, 12, and 24 months, while physical performance (range of motion [ROM], and limb symmetry indices [LSI] of isokinetic testing, single-leg and timed-6m hop) was compared up to 9 months postoperatively. Baseline characteristics and outcomes were similar, except thicker grafts in the LET group (8.9 vs. 8.7 mm, p = 0.047). At 3 months, Lemaire patients reported less pain (NRS pain 17.1 vs. 35.6, p < .001), but at 6 months, Lemaire patients had inferior LSI for timed-6m hop (87% vs. 96%, p = 0.003). At 9 months, Lemaire patients had similar return to sports, PROMs, and ROM, but had lower LSI for flexion endurance strength (88% vs. 97%, p = 0.041). At 12 months, no differences were seen in PROMs. In conclusion, Patients undergoing ACLR with LET had less pain at 3 months, but worse LSI for timed-6m hop at 6 months and worse LSI for flexion endurance strength at 9 months. Both groups showed similar performance on all other outcomes, indicating that ACLR with LET is not associated with increased stiffness, complications, or significant strength deficits. LEVEL OF EVIDENCE: : Level II prospective study.

Surface Attachment Points for Lateral Extra-articular Procedures Are in Close Proximity to the Femoral and Tibial Physes in Skeletally Immature Patients.

To compare clinical outcomes, postoperative stability, graft rerupture and return to sport (RTS) outcomes between ipsilateral peroneus longus tendon (PLT) and contralateral hamstring tendon (HT) autografts in isolated single-stage revision anterior cruciate ligament reconstruction (ACLR), and to evaluate the association between graft diameter and postoperative outcomes. This retrospective cohort study included 44 patients who underwent isolated single-stage revision ACLR between 2017 and 2023 (PLT: 23; HT: 21), with a minimum follow-up of 24 months. Additional ligament procedures and lateral extra-articular procedures were excluded. Graft choice was determined intraoperatively based on tunnel quality and graft availability following preoperative shared decision-making. Functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner), knee stability (Lachman and pivot-shift), American Orthopaedic Foot and Ankle Society (AOFAS) scores, complications and RTS outcomes were assessed. RTS was defined as achieving a postoperative Tegner score equal to or greater than the preinjury level. Logistic regression explored associations between graft diameter and postoperative instability, graft rerupture and RTS achieved. Receiver operating characteristic (ROC) analysis evaluated the discriminative ability of graft diameter for RTS. Mean age was 30.8 ± 6.8 years in the HT group and 31.0 ± 7.2 years in the PLT group, with comparable sex distribution between groups. Mean follow-up was 43.6 ± 9.3 months. Graft diameter was larger in the PLT group (8.8 ± 0.7 vs. 8.0 ± 0.6 mm; p < 0.001), while functional outcomes, postoperative stability and RTS rates were similar between groups (all p > 0.35). Overall RTS rate was 33/44 (75.0%). Greater graft diameter was associated with lower odds of postoperative instability and graft rerupture, and higher likelihood of RTS achieved. ROC analysis identified a graft diameter threshold of ≥8.25 mm for RTS prediction (area under the receiver operating characteristic curve [AUC] = 0.796). In isolated revision ACLR, graft diameter was associated with postoperative stability, graft survival and RTS outcomes, independent of graft type. Level III, retrospective comparative study.

Assess the robustness of randomized clinical trial (RCT) findings comparing outcomes after isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR plus lateral extra-articular procedures (LEAP) using both the fragility index (FI) and continuous fragility index (CFI). A systematic search was conducted across PubMed, EMBASE and Cochrane databases from inception to March 2025 in accordance with PRISMA guidelines. Two-arm randomized controlled trials comparing isolated ACLR with ACLR plus LEAPs were included if they reported statistically significant continuous or categorical outcomes. Overall, CFI and FI were calculated using validated methods, with the value demonstrating the minimum number of event reversals needed to make a finding nonsignificant. Outcome-specific indices were also analyzed when the same outcome was reported in ≥3 studies. Multivariable linear regression was used to identify factors associated with higher CFI or FI values. We identified 3819 studies, of which 17 met inclusion criteria and were analyzed, encompassing 2056 knees (30.3% female). The included studies had a mean age and follow-up period range of 18.8-34 years and immediate postoperative to 60 months, respectively. Across 23 significant continuous outcomes, the median CFI was 13.3 (interquartile ranges [IQR] 20.2), and for 21 categorical outcomes, the median FI was 1.6 (IQR 3). For primary outcomes, the median CFI was 3.8 (IQR 60.2), and the median FI was 3.0 (IQR 16). Regression analysis showed no predictors for higher CFI, while higher FI was significantly associated with fewer knees lost to follow-up, larger sample size, higher journal impact factor and longer follow-up. Many significant findings in RCTs comparing ACL reconstruction with or without LEAPs rely on few patient outcome changes to lose significance. Clinically, surgeons should interpret reported benefits cautiously, as small changes in outcomes could alter significance with stronger evidence stemming from studies with larger sample sizes and longer follow-up. Level I-II, meta-analysis.

Persistent rotational instability, reported in 15-35% of isolated anterior cruciate ligament (ACL) reconstruction remains a significant cause of graft failure and impaired return to sports. This has led toan increased interest in supplementing ACL reconstruction with anterolateral ligament (ALL) reconstruction to address residual rotational laxity. ALL reconstruction may better restore rotational stability compared to traditional lateral extra-articular procedures. The patient is positioned supine with the knee flexed at 90°, and standard landmarks are identified. Semitendinosus and gracilis tendons are harvested via a small incision. A quadrupled semitendinosus graft reconstructs the ACL, while the gracilis tendon reconstructs the ALL. Femoral tunnels for ACL and ALL reconstruction share a common anatomical entry point proximal and posterior to the lateral epicondyle. Tibial tunnels for the ALL are created below Gerdy's tubercle. Graft fixation is achieved with a suture disc on both femoral and tibial sides, ensuring physiological tension in extension. Patients begin immediate weight-bearing and range-of-motion exercises within controlled limits. A progressive rehabilitation protocol facilitates return to sports, allowing pivoting activities after six months. Combined ACL and ALL reconstruction using autologous hamstring grafts offers a reproducible surgical option for addressing rotational knee instability. Anatomical graft placement and minimally invasive techniques may offer the potential for improved clinical outcomes, decreased graft failure rates, and enhanced patient return to pre-injury activity levels.