Bone and Joint Institute

Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature

CE Hewison
MN Tran
N Kaniki
A Remtulla


Purpose: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction would provide greater control of rotational laxity and improved clinical outcomes compared with ACL reconstruction alone. Methods: Two independent reviewers searched 9 databases for randomized and nonrandomized clinical studies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All years and 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focused on biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the Cochrane Collaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MED-metric, San Diego, CA), and International Knee Documentation Committee scores. Results: The literature search yielded 3,612 articles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met the inclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the results were nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of the ACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. A meta-analysis showed a statistically significant difference for the pivot-shift test (P = .002, I-2 = 34%) in favor of ACL reconstruction with LET. No difference was found between the groups for International Knee Documentation Committee scores (P = .75, I-2 = 19%) and KT-1000/-2000 measurements (P = .84, I-2 = 34%). Conclusions: Meta-analysis showed a statistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficient internal validity, sample size, methodologic consistency, and standardization of protocols and outcomes.