Who should receive a lateral extra-articular tenodesis vs. an ALL reconstruction?
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ALL is less invasive, more effective
First, it is mandatory to establish that, regardless of the type of extra-articular reconstruction chosen, it is important to routinely perform an extra-articular reconstruction in patients at risk for ACL reconstruction failure.
In my clinical practice, I perform an extra-articular reconstruction in approximately 85% to 90% of ACL primary reconstruction cases and in all revision cases. With this practice, I have been able to significantly reduce my failure rate and improve the results of my patients undergoing ACL reconstruction, even those with increased risk factors for failure. Our recent studies show a failure rate of around 2% to 3% for primary cases and around 4.5% for revision cases, even in at-risk populations.
In addition to revision ACL reconstruction cases, I currently use the following indications for an associated extra-articular reconstruction in primary ACL reconstruction cases:
- young patients (younger than 25 years);
- high-grade pivot shift on physical examination;
- high-grade Lachman on physical exam;
- ligamentous laxity/knee hyperextension;
- practicing pivoting sports (football, volleyball, basketball, handball, skiing, etc.);
- anterolateral ligament (ALL) injury documented on imaging studies (MRI and ultrasound) performed in the acute phase of ACL injury;
- chronic ACL injuries;
- increased tibial inclination/slope in situations in which correction will not be performed; and
- situations in which the ACL graft has a small diameter.
Regarding when to perform an anatomical ALL reconstruction or when to perform a lateral extra-articular tenodesis (LET), my recommendation is based on the choice of graft I use for the ACL reconstruction, as both have shown to be effective. In reconstructions in which I use the hamstrings, the rectus femoris tendon or long allografts such as the Achilles tendon, I prefer to reconstruct the ALL. In situations in which I use the bone-patellar tendon-bone, the quadriceps or the peroneus longus, I perform a LET. In primary cases, I use the hamstrings more frequently, so I perform more ALL reconstructions than LET. Hamstrings are also the most used graft in the world for primary ACL reconstructions. In revisions, it depends on the graft used for the primary reconstruction, so I do use the LET in many cases.
I believe one of the advantages of ALL reconstruction, besides the fact it is an anatomical ligament reconstruction, is that we can use the same graft that we use for the ACL reconstruction with the single femoral tunnel technique. The results of this technique have already been published in several studies with a low failure rate. Although this is my preference, the reconstruction technique with independent tunnels is also effective. In addition, ALL reconstruction is less invasive and causes less pain than LET, according to a study we published on ACL revision cases. Even though the pain rate for LET can be higher, both techniques have similar clinical results according to recently published comparative studies.
That said, although I prefer to perform an ALL reconstruction most of the time, I believe choosing the best technique for each patient should be based on the characteristics of each patient and the experience of each surgeon.
- References:
- Ariel de Lima D, et al. Knee Surg Relat Res. 2021; doi:10.1186/s43019-021-00115-1.
- Ariel de Lima D, et al. Rev Bras Ortop. 2018; doi:10.1016/j.rboe.2018.09.007.
- Barroso BG, et al. Arthrosc Tech. 2024;doi:10.1016/j.eats.2024.103067.
- da Silva AGM, et al. Arthrosc Tech. 2023; doi:10.1016/j.eats.2023.08.028.
- Helito CP, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2019.03.059.
- Helito CP, et al. Arthroscopy. 2021;doi:10.1016/j.arthro.2021.01.045.
- Helito CP, et al. Arthroscopy. 2023;doi:10.1016/j.arthro.2022.06.039.
- Helito CP, et al. Arthroscopy. 2023;doi:10.1016/j.arthro.2023.01.101.
- Helito CP, et al. Arthroscopy. 2024;doi:10.1016/j.arthro.2023.07.057.
- Helito CP, et al. Knee Surg Sports Traumatol Arthrosc. 2018;doi:10.1007/s00167-018-4934-2.
- Helito CP, et al. Knee Surg Relat Res. 2022;doi:10.1186/s43019-022-00153-3.
- Helito CP, et al. Orthop J Sports Med. 2018;doi:10.1177/2325967117751348.
- Rayes J, et al. Am J Sports Med. 2022;doi:10.1177/03635465211061123.
- Ripoll T, et al. Am J Sports Med. 2023;doi:10.1177/03635465231197353.
- Saithna A, et al. J Knee Surg. 2021;doi:10.1055/s-0040-1701220.
- Sobrado MF, et al. Am J Sports Med. 2020;doi:10.1177/0363546520956266.
- Sonnery-Cottet B, et al. Am J Sports Med. 2017;doi:10.1177/0363546516686057.
Camilo P. Helito, MD, PhD, is a professor in the department of orthopedics and traumatology at the University of São Paulo in Brazil.
Optimize surgical environment
ACL reconstruction remains among the most common sports medicine surgeries performed worldwide. The overall goal of ACL reconstruction is to create a stable knee that allows function at a high level for activities of daily living, recreation and sport. While outcomes are generally favorable, postoperative laxity and/or retears are not uncommon. Factors contributing to postoperative laxity and/or retear are variable and include patient-specific factors, including age, sex, sport, compliance with rehabilitation and presence of baseline hyperlaxity, as well as surgeon-specific factors, including graft choice, technique and experience.
Certainly, traumatic re-rupture is always possible, even if the surgery was performed perfectly and the patient was rehabilitated perfectly. One strategy for improving postoperative stability and reducing retear rates includes lateral extra-articular augmentation procedures. The most common techniques for lateral augmentation during ACL reconstruction include LET and ALL reconstruction.
While lateral extra-articular augmentation is not new, it has grown in popularity during the last decade, both for primary and revision ACL reconstruction surgeries. Both LET and ALL reconstruction are viable strategies, each with their own advantages and disadvantages. While indications are constantly evolving, my current indications for lateral extra-articular augmentation include nearly all revision ACL reconstructions, as well as primary ACL reconstructions (or repairs) in high-risk athletes. What defines “high-risk” is subjective. In my practice this includes athletes younger than 30 years who demonstrate a “high-grade” pivot shift, baseline ligamentous laxity (elevated Beighton score, particularly with baseline knee hyper-extension greater than 10°) and athletes younger than 20 years who participate in high-risk sports (ie, soccer, basketball, etc.), especially female athletes.
In addition, I am more inclined to perform a lateral augmentation procedure when using a soft-tissue only graft for the ACL reconstruction (based on Stability Study data). Finally, patients with elevated tibial slope, known to be a risk factor for ACL reconstruction failure, may benefit from lateral extra-articular augmentation, although this remains controversial, particularly if there is fixed anterior tibial subluxation.
While I have experience performing both LET and ALL reconstruction, my preference is to perform a LET procedure, specifically via the modified Lemaire technique. Certainly, there are advantages and disadvantages to each approach. In my mind, the advantages and disadvantages of LET outweigh the advantages of ALL reconstruction. With the LET technique, no extra tissue is needed as we utilized the middle or posterior third of the iliotibial band, and only a single point of fixation is required. With the availability of low-profile and all-suture implants, a small incision can be used without concern for hardware irritation or for concern for convergence with the ACL femoral tunnel.
Historically, LET was associated with an elevated risk of over-constraint of the knee, particularly in the lateral compartment; however, more recent studies have demonstrated this not to be the case. In my experience, there have been no concerns with motion limitations postoperatively, and further, there are no rehabilitation changes to the ACL procedure when an LET is also performed.
With respect to ALL reconstruction, I think we are still figuring out how to best perform this procedure, specifically with respect to ensuring the graft is positioned appropriately, as this is a nonanatomic reconstruction, and tensioned appropriately, respecting the normal kinematics and biomechanics of the knee joint. In addition, the added expense of allograft tissue with two fixation devices (proximally and distally) increases cost and potentially infection risk. Notably, autograft (ie, hamstring autograft) could be used, but this is uncommon and adds surgical morbidity. Finally, the clinical outcomes and biomechanics of using a single graft for both ACL and ALL reconstruction, while attractive from a tunnel, hardware and cost perspective, need to be better understood.
In summary, one key to improving ACL outcomes is optimizing the surgical environment, particularly when certain unmodifiable risk factors are present. Lateral extra-articular augmentation represents an easy way in which to reduce retear rates and, when performed appropriately, is associated with minimal risk and morbidity. When comparing LET to ALL reconstruction, most studies suggest that the outcomes and complications are similar, and so I would encourage surgeons to use whichever technique they feel is most appropriate, reproducible and reliable in their hands.
Rachel M. Frank, MD, is an associate professor in the department of orthopedic surgery at the University of Colorado School of Medicine in Denver.
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