Association of Lateral Extra-Articular Tenodesis With Graft Failure and Return to Sport in Pivoting Athletes: A Multicenter Comparative Study of Augmented and Isolated ACL Reconstructions

Why clinicians should know about it

• Picked for Orthopedics and Sports Medicine (paper of the day, 6 August 2026): LET reduces graft failure and improves RTS in pivoting athletes

Abstract

BACKGROUND: Anterior cruciate ligament (ACL) rupture is common in high-risk pivoting sports, with rerupture threatening athletic careers. Lateral extra-articular tenodesis (LET) has been proposed to reduce graft failure; nonetheless, comparative multicenter data across graft types remain limited. PURPOSE: To compare graft failure, return to sport, and functional outcomes after primary anterior cruciate ligament reconstruction using bone-patellar tendon -bone or semitendinosus autografts, with or without lateral extra-articular tenodesis, in competitive pivoting athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors conducted a multicenter, prospective, intention-to-treat cohort study of 1260 competitive football and rugby athletes who underwent primary ACL reconstruction between 2018 and 2019. Participants were nonrandomly allocated to 4 groups according to graft choice and LET use, as determined by 16 individual treating surgeons: bone-patellar tendon-bone (BPTB) with modified Lemaire, semitendinosus tendon autograft (STRI) with modified Lemaire, isolated BPTB, and isolated STRI. At 5 years, evaluable follow-up data were available for 1186 of the 1260 athletes (94.1%). The primary endpoint was clinically relevant symptomatic knee instability consistent with graft failure, confirmed by imaging or revision surgery, defined as symptomatic knee instability confirmed by imaging or revision surgery. Follow-up included in-person medical examination with clinical stability testing when feasible and structured patient-reported questionnaires assessing knee stability and functional outcomes. RESULTS: Graft failure rates were similarly low in both augmented groups (0.8% for BPTB + Lemaire vs 0.9% for STRI + Lemaire groups), with no statistically significant difference between graft types and significantly lower than in nonaugmented reconstructions (P < .001). Return to sport (RTS) at the preinjury level at 18 months was achieved in 88.1% of athletes in the BPTB + Lemaire group and 82.7% in the STRI + Lemaire group, compared with 79.8% and 75.9% in isolated BPTB and STRI reconstruction groups, respectively (P < .001). Functional outcomes were similarly high in augmented groups, with mean International Knee Documentation Committee scores of 90.8 ± 6.8 for the BPTB + Lemaire group and 89.6 ± 7.2 for the STRI + Lemaire group, with no statistically significant differences between augmented graft types (P > .05). CONCLUSION: LET was associated with significantly reduced clinically relevant graft failure and reliable RTS in pivoting athletes, independent of graft type.

Abstract as published, via PubMed.