Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up

  • F. E. RowanEmail author
  • S. S. Huq
  • F. S. Haddad
Arthroscopy and Sports Medicine



The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria.


A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2 years. Stratified variable analysis of the groups was also performed.


There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52 months and 27 months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P < 0.001) favoured ACL reconstruction with LEAT compared to ACL reconstruction alone. Sports with frequent change of direction maneuvers and higher rates of ACL injury (rugby, soccer, skiing) favoured ACL reconstruction with LEAT versus ACL reconstruction alone (P = 0.001). No significant difference in re-operation rate or type of surgery was found between the two surgical groups after propensity matching but 13 patients in the ACL reconstruction-only group re-injured their ACL, 8 of whom required supplementary LEAT at the time of revision surgery.


Patient-reported outcomes and return to multi-directional sports after ACL reconstruction favour LEAT at the time of ACL reconstruction when narrow inclusion criteria are applied.


ACL Anterior cruciate ligament Lateral extra-articular tenodesis Pivot shift test Athlete 



There is no funding source.

Compliance with ethical standards

Conflict of interest

The senior author is a paid speaker and consultant and receives royalties from Smith and Nephew.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Noyes FR, Jetter AW, Grood ES et al (2015) Anterior cruciate ligament function in providing rotational stability assessed by medial and lateral tibiofemoral compartment translations and subluxations. Am J Sports Med 43:683–692. CrossRefGoogle Scholar
  2. 2.
    Irrgang JJ, Ho H, Harner CD, Fu FH (1998) Use of the international knee documentation committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Knee Surg Sport Traumatol Arthrosc 6:107–114. CrossRefGoogle Scholar
  3. 3.
    Noyes FR, Huser LE, Levy MS (2017) Rotational knee instability in ACL-deficient knees. J Bone Jt Surg 99:305–314. CrossRefGoogle Scholar
  4. 4.
    Zaffagnini S, Grassi A, Marcheggiani Muccioli GM et al (2018) The anterolateral ligament does exist. Clin Sports Med 37:9–19. CrossRefGoogle Scholar
  5. 5.
    Claes S, Vereecke E, Maes M et al (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328. CrossRefGoogle Scholar
  6. 6.
    Dodds AL, Halewood C, Gupte CM et al (2014) The anterolateral ligament: anatomy, length changes and association with the segond fracture. Bone Jt J 96:325–331. CrossRefGoogle Scholar
  7. 7.
    Kittl C, Inderhaug E, Williams A, Amis AA (2018) Biomechanics of the anterolateral structures of the knee. Clin Sports Med 37:21–31. CrossRefGoogle Scholar
  8. 8.
    Roessler PP, Schüttler KF, Stein T et al (2017) Anatomic dissection of the anterolateral ligament (ALL) in paired fresh-frozen cadaveric knee joints. Arch Orthop Trauma Surg 137:249–255. CrossRefGoogle Scholar
  9. 9.
    Lubowitz JH (2014) Anatomic ACL reconstruction produces greater graft length change during knee range-of-motion than transtibial technique. Knee Surg Sport Traumatol Arthrosc 22:1190–1195. CrossRefGoogle Scholar
  10. 10.
    Pernin J, Verdonk P, Si Selmi TA et al (2010) Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med 38:1094–1102. CrossRefGoogle Scholar
  11. 11.
    Devitt BM, Bouguennec N, Barfod KW et al (2017) Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis. Knee Surg Sport Traumatol Arthrosc 25:1149–1160. CrossRefGoogle Scholar
  12. 12.
    Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354. CrossRefGoogle Scholar
  13. 13.
    Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Anterolateral tenodesis or anterolateral ligament complex reconstruction: effect of flexion angle at graft fixation when combined With ACL reconstruction. Am J Sports Med 45:3089–3097. CrossRefGoogle Scholar
  14. 14.
    Guzzini M, Mazza D, Fabbri M et al (2016) Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players. Int Orthop 40:2091–2096. CrossRefGoogle Scholar
  15. 15.
    Zaffagnini S, Bruni D, Russo A et al (2008) ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up. Scand J Med Sci Sports 18:573–581. CrossRefGoogle Scholar
  16. 16.
    Inderhaug E, Stephen JM, El-Daou H et al (2017) The effects of anterolateral tenodesis on tibiofemoral contact pressures and kinematics. Am J Sports Med 45:3081–3088. CrossRefGoogle Scholar
  17. 17.
    Geeslin AG, Moatshe G, Chahla J et al (2017) Anterolateral knee extra-articular stabilizers: a robotic study comparing anterolateral ligament reconstruction and modified lemaire lateral extra-articular tenodesis. Am J Sports Med. Google Scholar
  18. 18.
    Zaffagnini S, Marcheggiani Muccioli GM, Grassi A et al (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45:3233–3242. CrossRefGoogle Scholar
  19. 19.
    Sonnery-Cottet B, Vieira TD, Ouanezar H (2019) Anterolateral ligament of the knee: diagnosis, indications, technique, outcomes. Arthrosc J Arthrosc Relat Surg 35:302–303. CrossRefGoogle Scholar
  20. 20.
    Gornitzky AL, Lott A, Yellin JL et al (2016) Sport-specific yearly risk and incidence of anterior cruciate ligament tears in high school athletes. Am J Sports Med 44:2716–2723. CrossRefGoogle Scholar
  21. 21.
    Fox AS (2018) Change-of-direction biomechanics: is what’s best for anterior cruciate ligament injury prevention also best for performance? Sport Med 48:1799–1807. CrossRefGoogle Scholar
  22. 22.
    Brooks JHM, Fuller CW, Kemp SPT, Reddin DB (2005) Epidemiology of injuries in english professional rugby union: part 1 match injuries. Br J Sports Med 39:757–766. CrossRefGoogle Scholar
  23. 23.
    Westin M, Harringe ML, Engström B et al (2018) Risk factors for anterior cruciate ligament injury in competitive adolescent alpine skiers. Orthop J Sport Med 6:232596711876683. CrossRefGoogle Scholar
  24. 24.
    Smith PA, Thomas DM, Pomajzl RJ et al (2019) A biomechanical study of the role of the anterolateral ligament and the deep iliotibial band for control of a simulated pivot shift with comparison of minimally invasive extra-articular anterolateral tendon graft reconstruction versus modified lemaire reconstruction after anterior cruciate ligament reconstruction. Arthroscopy. Google Scholar
  25. 25.
    Weiss WM (2018) Editorial commentary: technical advances in fixation for arthroscopic anterior cruciate ligament reconstruction won’t take the place of good technique…or a strong arm! Arthrosc J Arthrosc Relat Surg 34:2675–2676. CrossRefGoogle Scholar
  26. 26.
    Nguyen JT, Wasserstein D, Reinke EK et al (2017) Does the chronicity of anterior cruciate ligament ruptures influence patient-reported outcomes before surgery? Am J Sports Med 45:541–549. CrossRefGoogle Scholar
  27. 27.
    Dejour D, Vanconcelos W, Bonin N, Saggin PRF (2013) Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 37:193–199. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Trauma and Orthopaedic SurgeryUniversity College London HospitalLondonUK
  2. 2.The Princess Grace HospitalLondonUK

Personalised recommendations