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

Abstract

Background: The combination of lateral extra-articular tenodesis (LET) with primary single-bundle anterior cruciate ligament (ACL) reconstruction (ACLR) remains controversial. Purpose: To determine whether the combination of LET with single-bundle ACLR provides greater control of anterolateral rotatory instability and improved clinical outcomes compared with ACLR alone. Study Design: Systematic review; Level of evidence, 2. Methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases were searched between inception and July 1, 2020. Level 1 or 2 randomized controlled trials that compared isolated single-bundle ACLR with combined LET with ACLR were included. Data were meta-analyzed for the primary outcome measure of knee stability and the secondary outcome measures of patient-reported outcome scores, return to sports, and graft failure. Dichotomous variables were presented as relative risks (RRs), and continuous variables were presented as mean differences (MDs) and standardized MDs (SMDs). Results: A total of 6 studies involving 1010 patients were included. Pooled data showed that the ACLR+LET group had a lower incidence of the pivot shift (RR, 0.56 [95% CI, 0.45 to 0.69]; P < .00001), a higher postoperative activity level (MD, 0.47 [95% CI, 0.15 to 0.78]; P = .004), and a lower risk of graft failure (RR, 0.35 [95% CI, 0.21 to 0.59]; P < .00001) than did the ACLR group. However, there were no statistically significant differences in primary outcomes including positive Lachman test findings (RR, 0.76 [95% CI, 0.48 to 1.21]; P = .26) or side-to-side differences (SMD, –0.43 [95% CI, –0.95 to 0.09]; P = .11) or in secondary outcomes including International Knee Documentation Committee scores (SMD, 0.25 [95% CI, –0.06 to 0.56]; P = .11) or Lysholm scores (SMD, 0.28 [95% CI, –0.06 to 0.62]; P = .11). Although the overall rate of return to sports was not significantly different between the groups (RR, 0.97 [95% CI, 0.90 to 1.03]; P = .33), the activity level was higher in the ACLR+LET group. Conclusion: The addition of LET to primary single-bundle ACLR produced greater knee stability, a higher activity level, and a lower incidence of graft failure than did ACLR alone. There may be a role for adding LET to ACLR for the treatment of ACL injuries.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

“…It demonstrated that concomitant LET results in a 3-fold lower risk of graft failure. 33 The second relevant finding of the present study is that combining LET with ACL reconstruction significantly improved both anteroposterior and rotatory knee stability in this skeletally immature cohort without increasing the risk of complications. This is in accordance with biomechanical evidence that demonstrates that LET in combination with ACL reconstruction significantly reduces both anterior tibial translation and tibial internal rotation as compared with isolated ACL reconstructions.…”

“…2,17,44 Recently, combining a lateral extra-articular tenodesis (LET) with ACL reconstruction has been reported to significantly decrease failure rates while improving objective rotatory stability and the postoperative activity level. 33 As a result, LET has been strongly recommended for patients at high risk of graft failure. Indications include patients \25 years of age, patients practicing pivoting sports, patients with joint hyperlaxity, and patients with a high-grade preoperative instability.…”

The anterolateral capsule is infrequently damaged as evaluated arthroscopically in patients undergoing anatomic ACL reconstruction

“…The most important findings of this retrospective case series of 117 ACL-injured knees were: (1) ALC injury, visualized as hemorrhage of the anterolateral capsule during diagnostic arthroscopy, was observed in 19% of ACL-injured knees, an injury incidence significantly less than that observed on MRI (53%) or ultrasound (63%); (2) ALC injury incidence and severity did not significantly differ between MRI and US grading scales; (3) No ALC injury grading scale on any imaging modality meaningfully correlated with physical examination maneuvers for anterolateral knee stability, including Lachman, anterior drawer, and pivot shift tests.…”

“…The anterolateral complex (ALC) of the knee, comprised of several structures including the anterolateral capsule and its variable thickening, most recently referred to as the anterolateral ligament (ALL), is a secondary stabilizer to the ACL in controlling anterolateral rotatory stability of the knee. [1] Surgical augmentation of the ALC combined with anatomic ACLR has been reported to improve anterolateral rotary knee stability and reduce graft failure as compared to anatomic ALCR alone at short-term follow-up in a young and active patient population [2][3][4][5] but the long-term outcomes and indications for ALC augmentation remain unclear. [1] Limiting efforts to define surgical indications for ALC augmentation is the variability in the reported incidence of concomitant ALC injury.…”

Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights

“…A meta-analysis of 1,010 patients from six randomized controlled trials by Mao et al 114 illustrated a lower risk of graft failure in those who had ACLR and LET compared to those who had isolated ACLR. Of significance is the STABILITY study by Getgood et al 117 This is the largest randomized multicenter study to date, looking at ACLR clinical failure between two ACLR groups – single-bundle hamstring tendon autograft without LET and with LET – in individuals between 14–25 years old.…”