Felipe Moreira MD, Merce Reverté MD PhD, Enric Castellet MD, and Joan Minguell MD PhD Vall d’Hebron University Hospital, Barcelona, Spain Intra‐articular reconstruction has become the technique of choice to address ACL deficiency. However, intra‐articular reconstruction does not restore normal knee kinematics and failure rate also remains a factor to consider in many cases, especially in high‐demand young athletes.1,2 In the past two decades, many surgeons have recommended extra‐articular reconstruction in conjunction with an intra‐articular technique in order to address normal kinematics and reduce failure rate. It is our impression that the use of additional extra‐articular procedures is increasing in number, especially in challenging primary cases and revisions. By attempting to control rotation laterally, further away from the pivot point of the knee, extra‐articular reconstruction may be better suited to control rotational motion by having a better lever arm.3 A simple intra‐articular procedure combined with an extra‐articular augmentation may achieve better clinical results, while also diminishing failure rates. The quality of literature addressing results of lateral extra‐articular procedures associated with ACLR is highly variable, with levels I–IV evidence. Studies lack standardization of protocols and outcomes. The majority of the outcome papers are case series or cohort studies. There are seven randomized controlled trials (RCTs),4–10 five recent systematic reviews,11–15 and one large trial currently underway.16 A growing number of RCTs examine the effect of extra‐articular augmentation. The trials differ in the type of LET and intra‐articular reconstruction, outcome measures, and definitions of failure. Drawing firm and reliable conclusions is difficult based on this current highly heterogeneous data set. In total, seven RCTs were found.4–10 Only one study demonstrated improved patient‐reported outcomes for patients undergoing ACLR associated with LET over controls(6).6 In this study, 75 patients were randomized evenly to three treatment groups. These consisted of: (i) the Marcacci technique (ACLR+LET), (ii) a four‐strand, single‐bundle hamstring ACLR, or (iii) a bone–patella–bone ACLR. At five‐year follow‐up the LET group had higher subjective International Knee Documentation Committee (IKDC) scores and also a quicker return to sport. Later on, some of the same authors in a different study found that, when compared to a double‐bundle group, the Marcacci technique performed worse in terms of IKDC scoring and pivot shift grading.8 Higher return to sport rates were seen in the double‐bundle group, with the Marcacci cohort returning to sport more quickly. The Standard ACL Reconstruction versus ACL and Lateral Extra‐Articular Tenodesis (STAbiLiTY) study is a recently‐completed RCT of 600 divided in two groups (ACLR + modified Lemaire LET vs ACLR), focusing on high‐risk patients, coordinated by the University of Western Ontario.16 The trial includes patients 14 to 25 years old with an ACL deficient knee who play competitive pivoting sports, and have a grade 2 pivot shift or generalized ligamentous laxity. Participants are randomized to hamstring ACLR or ACLR with an iliotibial band‐based LET (modified Lemaire). The primary outcome measure is graft failure at two years, with secondary outcomes being patient‐reported outcome scores, objective functional outcomes, biomechanical assessment, imaging, return to activity, adverse events, and cost outcomes. Preliminary results of the trial have been presente,17 and while the interim results should be interpreted with caution, they appear favorable for LET. Failure rates and the rate of asymmetric pivot shift are significantly lower in favor of the LET procedure. However, this appears to come at the cost of increased early morbidity, with increased pain and reduced lower limb function at three months.17 Rotational stability may not be restored by intra‐articular reconstruction alone. Subjectively measured as a positive pivot shift, this instability may be negatively associated with subjective and objective outcomes.18,19 Renewed interest in LET is based on its important role in biomechanical stability. Nevertheless, over‐constraint has also been linked to OA. Despite the reported risk of joint over‐constraint, consideration should be given to reconstructing the anterolateral structures and the ACL concurrently to maximally restore both anterior tibial translation and rotatory stability. However, the role of LET in improving rotational knee stability remains a controversial subject.12 To reduce rotational laxity might mean reducing residual pivot shift, and increasing patient satisfaction and functional stability, though it may also risk over‐constraint. Most of the studies discussed in Question 1 also report on rotational laxity and OA, with level I–IV evidence. The same seven RCTs are available,4–10 one meta‐analysis,14 as well as the STAbiLiTY trial.16 Level IV evidence has been found in relation to meniscal lesions.13,20
140 Lateral Extra‐Articular Tenodesis Procedures and the Anterolateral Ligament
Clinical scenario
Top three questions
Question 1: In patients undergoing anterior cruciate ligament reconstruction (ACLR), does the addition of lateral extra‐articular tenodesis (LET), compared to ACLR alone, improve function, and return to sport results while diminishing failure rate?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Randomized controlled trials
Current trials
Resolution of clinical scenario
Question 2: In patients undergoing ACLR, does the addition of LET, compared to ACLR alone, reduce rotational laxity, thus preventing osteoarthritis (OA) and meniscal lesions?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Randomized controlled trials
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
