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

Abstract

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 ( P = .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%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .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.

Supplementary Lateral Extra-articular Tenodesis for Residual Anterolateral Rotatory Instability in Patients Undergoing Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials

“…Titles and abstracts were reviewed, and the full text of 31 articles was examined. Ultimately, 6 RCTs 4,8,18,45,46,51 were included in this review (Table 1).…”

“…Results from the quality assessment of included studies are summarized in Figure 3. One study 8 was rated as having a high risk of selection bias because it reported unblinded block randomization for group allocation. Also, 2 studies 46,51 reported that participants were allocated randomly but did not adequately describe the randomization method, thus resulting in an unclear risk of bias rating.…”

“…However, this conclusion was contradicted by several other RCTs. 4,8,45 Another study 8 indicated a risk of lateral compartment osteoarthritis after 19 years when LET was combined with ACLR, but 2 other European studies with follow-up periods of over 20 years did not demonstrate an increased rate of osteoarthritis development with the addition of LET. 36,52 Several systematic reviews with meta-analyses have also attempted to address which treatment plan is most beneficial.…”

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

“…Some of the important long-term findings include greater allograft failures compared with autografts 21 and high incidence of osteoarthritic changes in reconstructed knees ranging from 22% to 100%. [60][61][62][63][64][65] There were no significant differences in…”

“…outcomes reported between bioabsorbable or metal screws for graft fixation, 66 patellar versus hamstrings, 62,63,[67][68][69] open versus arthroscopic, 61 or singleversus double-bundle reconstructions 65 (Table 5). 21,40,[59][60][61][62][63][64][65][66][67][68][69][70][71]…”