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    The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis. Devitt Brian M,Bell Stuart W,Ardern Clare L,Hartwig Taylor,Porter Tabitha J,Feller Julian A,Webster Kate E Orthopaedic journal of sports medicine Background:The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial. Purpose:To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR. Study Design:Systematic review; Level of evidence, 3. Methods:Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures. Results:Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; = .008; = 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; = .10; = 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes. Conclusion:In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes. 10.1177/2325967117731767
    No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Getgood Alan,Hewison Christopher,Bryant Dianne,Litchfield Robert,Heard Mark,Buchko Greg,Hiemstra Laurie A,Willits Kevin R,Firth Andrew,MacDonald Peter, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association PURPOSE:To assess the functional outcomes of patients included in the Stability Study randomized controlled trial comparing anterior cruciate ligament reconstruction (ACLR) alone with ACLR with lateral extra-articular tenodesis (LET) at 6, 12, and 24 months postoperatively. METHODS:Six hundred eighteen patients undergoing ACLR, all under the age of 25 years either returning to contact pivoting sport or displaying signs of high-grade rotatory laxity or generalized ligamentous laxity, were randomly assigned to receive ACLR alone or ACLR plus LET. A total of 356 of these patients were randomized at centers participating in the functional assessments. Our primary outcome was Limb Symmetry Index, calculated using a series of 4-hop tests at 6, 12, and 24 months postoperatively. Secondary outcome measures included pain, patient-reported function, and isokinetic strength testing. RESULTS:We found no statistically significant difference in the proportion of patients either unwilling or unfit to complete the hop testing in the ACLR alone or ACLR with LET group at 6 months (40 vs 40 respectively; P = 1.00), 12 months (25 vs 27; P = .76), and 24 months (21 vs 23; P = .87). Of those who completed hop testing, there were no statistically significant differences between groups in Limb Symmetry Index at 6, 12, or 24 months. Self-reported function (Lower Extremity Functional Score) significantly favored the ACLR alone group at 3 (P = .01) and 6 months (P = .02) postoperative but was similar by 12 months postoperative. Pain scores (P4) also showed a statistically significant difference in favor of the ACL alone group, but this also resolved by 6 months. Quadriceps peak torque (P = .03) and average power (P = .01) were also significantly different in favor of the ACLR alone group at 6 months postoperative; however, these were similar between groups by 12 months postoperative (P = .11 and P = .32, respectively). CONCLUSIONS:The addition of a LET to ACLR results in slightly increased pain, a mild reduction in quadriceps strength, and reduced subjective functional recovery up to 6 months postoperatively. However, these differences do not have any impact on objective function as measured by hop test limb symmetry index. LEVEL OF EVIDENCE:I, Randomized Controlled Trial. 10.1016/j.arthro.2020.02.015
    Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis. Ra Ho Jong,Kim Jun-Ho,Lee Dae-Hee Archives of orthopaedic and trauma surgery BACKGROUND:Anterolateral augmentation procedures can be divided into traditional lateral extra-articular tenodesis (LET) and modern anterolateral ligament (ALL) reconstruction. Nevertheless, no studies have compared the clinical results between LET and ALL reconstruction, when combined with intra-articular ACL reconstruction. This study was therefore designed to compare the clinical results, including the anterior translation, rotational laxity, and patient-reported outcomes, in a group of patients who underwent ACL reconstruction combined with LET or ALL reconstruction. METHODS:All studies systematically searched until March 2018 without any language restriction that reported the results of a lateral extra-articular stabilization procedure using either LET or ALL reconstruction methods combined with ACL reconstruction were evaluated. Two reviewers independently recorded data from each study, including the sample size, improvement in Lysholm score, and the number of patients with each grade of knee laxity using Lachman and pivot shift tests. RESULTS:The pooled results of ten studies showed that the postoperative proportion of knees with grade 2 or 3 on the Lachman test was significantly higher following LET compared with ALL reconstruction in combination with ACL reconstruction (10.8%, 95% confidence interval [CI]: 6.6-17.1% vs. 1.5%, 95% CI 0.5-4.5%; p = 0.001). However, the pooled results of 12 studies showed that the proportion of knees that belonged to grade 2 or 3 on the pivot shift test, indicating poor rotational stability, was similar between these two techniques (4.9%, 95% CI 2.0-11.5% vs. 2.3%, 95% CI 1.1-4.5%; p = 0.101). The pooled improvements in Lysholm scores in these two groups were also similar (32.3, 95% CI 26.8-37.9 vs. 25.7, 95% CI 16.7-34.7, p = 0.218). CONCLUSION: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. 10.1007/s00402-020-03393-8
    A Randomized Controlled Trial of Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up. Castoldi Marie,Magnussen Robert A,Gunst Stanislas,Batailler Cécile,Neyret Philippe,Lustig Sébastien,Servien Elvire The American journal of sports medicine BACKGROUND:Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone-patellar tendon-bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. PURPOSE:The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. STUDY DESIGN:Randomized controlled trial; Level of evidence, 2. METHODS:This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). RESULTS:Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups ( = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. CONCLUSION:There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome. 10.1177/0363546520914936
    Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Getgood Alan M J,Bryant Dianne M,Litchfield Robert,Heard Mark,McCormack Robert G,Rezansoff Alex,Peterson Devin,Bardana Davide,MacDonald Peter B,Verdonk Peter C M,Spalding Tim, ,Willits Kevin,Birmingham Trevor,Hewison Chris,Wanlin Stacey,Firth Andrew,Pinto Ryan,Martindale Ashley,O'Neill Lindsey,Jennings Morgan,Daniluk Michal,Boyer Dory,Zomar Mauri,Moon Karyn,Pritchett Raely,Payne Krystan,Fan Brenda,Mohan Bindu,Buchko Gregory M,Hiemstra Laurie A,Kerslake Sarah,Tynedal Jeremy,Stranges Greg,Mcrae Sheila,Gullett LeeAnne,Brown Holly,Legary Alexandra,Longo Alison,Christian Mat,Ferguson Celeste,Mohtadi Nick,Barber Rhamona,Chan Denise,Campbell Caitlin,Garven Alexandra,Pulsifer Karen,Mayer Michelle,Simunovic Nicole,Duong Andrew,Robinson David,Levy David,Skelly Matt,Shanmugaraj Ajaykumar,Howells Fiona,Tough Murray,Spalding Tim,Thompson Pete,Metcalfe Andrew,Asplin Laura,Dube Alisen,Clarkson Louise,Brown Jaclyn,Bolsover Alison,Bradshaw Carolyn,Belgrove Larissa,Millan Francis,Turner Sylvia,Verdugo Sarah,Lowe Janet,Dunne Debra,McGowan Kerri,Suddens Charlie-Marie,Declercq Geert,Vuylsteke Kristien,Van Haver Mieke The American journal of sports medicine BACKGROUND:Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. HYPOTHESIS:We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. STUDY DESIGN:Randomized controlled trial; Level of evidence, 1. METHODS:This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. RESULTS:A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 ( = .003) and KOOS ( = .007), with KOOS pain persisting in favor of the ACLR group to 6 months ( = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale ( = .11). CONCLUSION:The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. REGISTRATION:NCT02018354 ( ClinicalTrials.gov identifier). 10.1177/0363546519896333