Selective approach to lateral extra-articular tenodesis achieves low anterior cruciate ligament graft rupture rates, while posterior tibial slope and static anterior tibial translation remain major risk factors

This study aimed to evaluate anterior cruciate ligament (ACL) graft rupture in a selective approach to lateral extra-articular tenodesis (LET), with a focus on the impact of posterior tibial slope (PTS) and static anterior tibial translation (SATT) on graft rupture rate. This retrospective study included patients who underwent primary ACL reconstruction (ACLR) using hamstrings autograft between 2014 and 2018, with a minimum follow-up of 6 years. LET was performed based on specific indications (pivot shift grade 2-3, hyperlaxity and genu recurvatum) in adult patients and systematically in those under 18 years of age. Demographic variables, associated procedures, ACL graft rupture and time to rupture were recorded. Preoperative radiographs were used to measure PTS and SATT. Univariate and multivariate analyses were performed to identify risk factors for graft rupture. A total of 839 patients were eligible. Follow-up was obtained for 705 patients (mean age 30.5&#x2009;&#xb1;&#x2009;10.9 years; 38% female). Forty-one ACL graft ruptures were identified (5.8%). Among adult patients (&#x2265;18 years), the graft rupture rate was 4.5% in the ACLR&#x2009;+&#x2009;LET group versus 5.4% in the isolated ACLR group (p&#x2009;=&#x2009;0.673). Risk factors significantly associated with graft rupture included PTS&#x2009;&#x2265;&#x2009;12&#xb0; (odds ratio [OR]&#x2009;=&#x2009;3.0; 95% confidence interval [CI]&#x2009;=&#x2009;1.5-6.2; p&#x2009;=&#x2009;0.001), SATT&#x2009;&#x2265;&#x2009;5&#x2009;mm (OR&#x2009;=&#x2009;2.7; 95% CI&#x2009;=&#x2009;1.3-5.5; p&#x2009;=&#x2009;0.006), age&#x2009;<&#x2009;18 years (OR&#x2009;=&#x2009;2.3; 95% CI&#x2009;=&#x2009;1.0-3.9; p&#x2009;=&#x2009;0.017) and lateral meniscal injuries (OR&#x2009;=&#x2009;2.3; 95% CI&#x2009;=&#x2009;1.1-5.0; p&#x2009;=&#x2009;0.041). The highest graft rupture rate occurred in patients <18 years with both PTS&#x2009;&#x2265;&#x2009;12&#xb0; and SATT&#x2009;&#x2265;&#x2009;5&#x2009;mm (2/7; 29%). A selective, indication-based approach to LET in patients &#x2265;18 years and systematic LET in patients under 18 years of age was associated with low ACL graft rupture rates. Higher PTS, SATT, younger age and lateral meniscal injury were associated with an increased risk of graft rupture. These findings should be interpreted within the limitations of the study design. Level III, retrospective case-control study.